Age: 77.0
Sex: M
Vaccine: COVID19
Symptoms: Bone scan normal, Brain natriuretic peptide increased, COVID-19, Capillary nail refill test, Cardiomegaly
Clinical narrative: Hospitalized;  COVID positive (2.16.22);  Fully vaccinated PLUS booster Admission Date: 2/15/2022 Discharge Date: 2/23/2022 Brief history and medical decision making:  Patient is 77-year-old male with an extensive past medical history who presented to the emergency department with worsening shortness of breath and increased work of breathing for the previous 4 days.  He had cough chills fever rigors and workup in the emergency department showed a significant white count and chest x-ray findings concerning for pneumonia.  He was started on antibiotics after blood cultures were obtained film array was positive for COVID see is placed in isolation.  He was outside the window for remdesivir continued on steroid therapy and supportive care.  Unfortunate a his blood cultures grew out Pseudomonas and 2/2 blood cultures and Infectious Disease was consulted.  Pneumonia is felt to be the likely source and he was converted from Zosyn to Cipro prior to discharge.  He was discharged home to complete his oral antibiotics and obtain a repeat blood culture 7 days after antibiotic therapy concluded. DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Community acquired pneumonia, bilateral   HOSPITAL COURSE: Patient is a 77 year old male with a history of COPD, HTN, DM, atrial fib, pacemaker, chronic DVT R leg, pulmonary embolism, pulmonary hypertension, and heart failure who presented to ER with significantly worsening shortness of breath and work of breathing for 4 days. He also reports cough, chills, and rigors. He denies chest pain, nausea, vomiting, and diarrhea. The patient went to see his pulmonologist on Friday 2/11 regarding work of breathing who increased his Bumex to 4 mg bid (from 3 mg) and ordered a CXR. The patient has had two xrays one day apart that look similar. One reported vascular congestion with pleural effusion and the other severe multifocal pneumonia. His BNP is at baseline at 2,287 (last 2,498, 2,811). His oxygen requirement is up to 6 liters; baseline 2.5 to 3 liters with sleep only. His initial temp in ER was 38.2. WBC count elevated to 24.81. Procal and lactic acid normal.  The patient was given a 3 liter bolus in ER for meeting sepsis criteria, and started on rocephin and azithromycin.  The patient is being admitted with CAP for continued monitoring and treatment.    Blood cultures were obtained as well as a film array to further evaluate for cause of his pneumonia.  Urinalysis was abnormal so urine cultures were also obtained.  Film array came back positive for COVID so the patient was placed in isolation; he had no recent exposures and is vaccinated against COVID.  His clinical course was not consistent with acute COVID infection and his symptom onset and renal function would contraindicate remdesivir therapy.  He did have some wheezing suggesting a chronic obstructive pulmonary disease exacerbation and was placed on steroids.  Patient was placed in respiratory isolation though was not clear that his pneumonia is related to COVID.   Blood cultures did grow out Pseudomonas 2/2.  Repeat blood cultures were obtained and have been negative.  Because of his Pseudomonas bacteremia infectious diseases was consulted.  It was felt that pneumonia was likely the source of the infection but there was concern regarding his chronic right foot wound.  Further imaging was recommended but the patient is unable to undergo MRI secondary to pacemaker placement.  A CT scan without contrast was not definitive to rule out osteomyelitis.  Continued evaluation with a bone scan was ordered and did not show evidence of osteomyelitis.  Infectious disease follow the patient and recommended Cipro 500 mg BID to completed a 14-day course (2/17-3/3/22); he was transitioned from Zosyn to Cipro before discharge. We recommended a blood culture 7 days after completion of CIPRO.   In the meantime, the patient's respiratory status significantly improved likely in part to diuresis with a 4 KG weight loss. He did have some hypotension so his diuretics and metoprolol were held initially.  Metoprolol and Bumex were added back to his regimen. These were titrated down prior to discharge to Metoprolol 12.5 mg bid and Bumex 2 mg bid. He remained off Inspra during his stay and will be instructed to do so at discharge until his pulmonologist recommends otherwise. He had a home oxygen test prior to discharge and it was determined the patient did not need oxygen at rest, but required 4 liters with activity. PT and OT evaluated the patient and did not feel he needed services at discharge.    The patient was discharged home in stable condition with the above changes made to his medications. He is recommended to follow up with his pulmonologist and PCP for further management of chronic conditions and to ensure resolution of bacteremia.