Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Epistaxis, Exposure to SARS-CoV-2, Fibrin D dimer increased, Glomerular filtration rate decreased, Haemoglobin decreased
Clinical narrative: Patient currently inpatient at (4) days admission.  Acute respiratory failure with hypoxia Assessment & Plan Hypoxia at home and progressive oxygen needs in the ER Currently requiring HFNC +NRB mask as patient is mouth breather Suspect this is multifactorial with COVID, possible bacterial superinfection as well as high suspicion for PE Treat with dexamethasone, antibiotics and place on heparin gtt  Wean oxygen as tolerated Patient is DNR   * Pneumonia due to COVID-19 virus Assessment & Plan CXR showing left sided pneumonia, uncommon presentation for COVID Procal elevated so treating with antibiotics for possible bacterial superinfection Symptom onset: 11/20 Isolation: Severe Respiratory Vaccination Status: Vaccinated, no booster Continue supplemental O2, Titrate/wean to maintain SpO2>92%, currently on HFNC 55% plus NRB mask Continue Dexamethasone 1/10 Outside window for Remdesivir  Encourage Self Prone, IS, deep breathing and ambulation as tolerated  Symptomatic Treatment: Anti Tussives, Anti Emetics, Analgesics VTE PPx:Due to high clinical suspicion for PE place on heparin gtt  Daily CBC, CMP, CRP, D-Dimer Monitor I/O, daily weight, creatinine Maintain net neutral to negative fluid balance q24 Code Status: DNR Dopplers of upper and lower extremities pending     Elevated D dimer Assessment & Plan D dimer 5860 High clinical suspicion for PE. Patient has significant elevation in BNP as well. Due to renal function is unable to undergo CTA thorax.  He had been on xarelto previously for afib but has been off of this since 11/2. Start heparin gtt and monitor closely Check dopplers of upper and lower extremities  Obtain limited echo   Anemia Assessment & Plan Had toe amputation last month and some epistaxisis earlier this month  Outpatient labs revealed hgb of 12.3 which is lower than baseline Patient was told to stop his xarelto No reports of further bleeding Starting heparin gtt for high suspicion of PE, continue to monitor hemoglobin   AKI (acute kidney injury) Assessment & Plan Cr baseline around 2-2.3 Now with AKI, Cr 2.6 on admission Monitor renal function closely with diuresis  Avoid nephrotoxins and renally dose medications     Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure Assessment & Plan No significant change in edema BNP elevated at 34,585, felt to be possibly related to PE Will check limited echo Given IV lasix in ER, continue   CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min Assessment & Plan Appears to be baseline CKD 3/ borderline CKD4  Now with AKI See plan above    OSA (obstructive sleep apnea) Assessment & Plan Monitor pulse ox Currently requiring HFNC   Hypertension Assessment & Plan Monitor BP closely Continue home metoprolol Hold torsemide and aldactone while getting IV lasix   Atrial fibrillation  Assessment & Plan Was taken off of xarelto on 11/2 after hemoglobin found to be lower than baseline  On metoprolol for rate control, continue Given high concern for PE will start heparin gtt             Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 79 y.o. male who presents today with shortness of breath. The patient reports that he began having symptoms on 11/20. He is vaccinated for COVID but has not had a booster. He has had poor appetite, chills, fevers, cough and shortness of breath as well as abdominal pain and diarrhea. His wife came down with symptoms on the same day. They believe he was exposed when he was sent to Hospital on 11/8 for follow up on his drop in hemoglobin. He had a pulse ox at home and was noting hypoxia in the 70's prompting him to come to ER for evaluation.    In the ER the patient was found to be hypoxic to 60% on room air on presentation. He quickly progressed to HFNC with a NRB mask due to being a mouth breather. He had labs showing significant elevation in BNP and D dimer. There was high clinical concern for PE however due to AKI a CTA thorax was unable to be obtained. Dopplers of upper and lower extremities obtained. He had an elevated procal and was started on antibiotics and had blood cultures ordered. The hospitalist team was contacted for admission and further management.   Of note the patient's daughter reports that his xarelto was stopped on 11/2 as his PCP noted a drop in hemoglobin to 12. He had his toe amputated last month and then had some epistaxis earlier this month and so the decision was made to stop the xarelto and continue to monitor.      Patient Active Problem List Diagnosis ? Status post total knee replacement ? Atrial fibrillation ? Non-ischemic cardiomyopathy ? Chronic combined systolic and diastolic CHF (congestive heart failure) ? Hypertension ? OSA (obstructive sleep apnea) ? CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min ? Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure  ? Pneumonia due to COVID-19 virus ? Acute respiratory failure with hypoxia ? AKI (acute kidney injury)  ? Anemia ? Elevated D dimer