Age: 80.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Acute respiratory failure, Blood culture, Blood lactic acid, Blood pH increased, Blood pressure decreased
Clinical narrative: Hospitalized 10/6/2021; COVID-19 positive 10/6/2021; fully vaccinated  CHIEF COMPLAINT: FEVER, SHORTNESS OF BREATH, and COUGH   MEDICAL DECISION MAKING/ ASSESSMENT & PLAN:   81 female with diabetes and hypertension and cardiomyopathy who presents today with worsening cough shortness of breath.  Seen emergently upon arrival.  Oxygen saturation in the mid 80s.  Placed on 6 L nasal cannula with improvement to the low 90s.  Obvious respiratory distress.  IV was established routine blood work were obtained.  Chest x-ray was obtained.  COVID-19 was obtained and positive.  Patient initially appeared septic but with the COVID-19 being positive, antibiotics were temporarily held as were fluids.  However, septic laboratory work had been obtained with reassuring lactic acid blood cultures pending pH 7.49 pCO2 of 30 consistent with her hyperventilation, urinalysis no signs of infection but significant ketones but procalcitonin was very elevated at greater than 60. For this reason, antibiotics were started and she was started on fluids receiving a total of 2 L due to slightly softer blood pressures with maps in the mid 60s.  She was given 6 mg dose of oral Decadron for the hypoxia in the setting of COVID-19.  X-ray described below which does show evidence of pneumonia which is likely a mix of COVID and bacterial given the elevated procalcitonin.  Her temperature was 40° on arrival she received Toradol and Tylenol and defervesced to 37.8.  She maintained her oxygen saturation on 6 L. she was admitted to the hospital service due to bed availability for further care. 10/8/2021 note: Severe COVID- 19 Pneumonia with Acute Hypoxemic Respiratory Failure - Pfizer SARsCOV2 vaccine 3/24/21 and 4/17/21 - symptoms started 9/30 - COVID 19 PCR Positive on 10/6 - CXR with findings concerning for viral  pneumonia - oxygen requirement: 13L intermediate NC with O2 sat 92% - Dexamethasone day #3 - IV Remdesivir Day #3              -due to risk for renal and liver toxicity, this medication requires monitoring with daily labs  - Lasix yesterday - will hold additional doses today and reassess tomorrow - daily labs CBC w/ differential, CMP, CRP, Ddimer  (CRP 243.5 today from 337.7yesterday; D-dimer 1670 today from 2420 yesterday) - continuous pulse oximetry  - VTE prophylaxis with Lovenox  - encourage prone position Severe Sepsis secondary to COVID 19 PNA and possible bacterial pna- present on admission  - Strep pneumo and legionella antigens negative  - MRSA not detected via PCR  - WBC 27.14 from 33.13 - Levaquin abx day #3 - blood cultures X 2 NG 24 hours Note 10/10/2021: Severe COVID- 19 Pneumonia with Acute Hypoxemic Respiratory Failure oxygen requirement:  High-flow nasal cannula 70% - Dexamethasone day #5/10 - IV Remdesivir Day #5/5 Severe Sepsis secondary to COVID 19 PNA and possible bacterial pna- present on admission  - WBC decreased down to 15.69 Note from 10/12/2021: Severe COVID- 19 Pneumonia with Acute Hypoxemic Respiratory Failure oxygen requirement:  High-flow nasal cannula 40% - Dexamethasone day #7/10 - IV Remdesivir Day #5/5 complete 10/10/21 Note from 10/14/2021: Patient has been treated with remdesivir, Decadron, and Levaquin.   Dispo: She is making improvement in her O2 status goal but needs to be less than 4 L with ambulation for discharge to home. oxygen requirement:  Intermediate nasal cannula 10L Note 10/17/2021: Plan Severe COVID- 19 Pneumonia with Acute Hypoxemic Respiratory Failure - Pfizer SARsCOV2 vaccine 3/24/21 and 4/17/21 - symptoms started 9/30 - COVID 19 PCR Positive on 10/6 - CXR with findings concerning for viral  pneumonia - oxygen requirement:  Intermediate nasal cannula 10L - Dexamethasone day #11 - IV Remdesivir Day #5/5 complete 10/10/21 - daily labs CBC - continuous pulse oximetry  - VTE prophylaxis with Lovenox q 12 h  - encourage prone position   Pt. Continues on 6L HFNC   Severe Sepsis secondary to COVID 19 PNA and possible bacterial pna- present on admission  - Strep pneumo and legionella antigens negative  - MRSA not detected via PCR  - WBC stable at 18.23  - Levaquin #7/7 completed 10/12