Age: 99.0
Sex: M
Vaccine: COVID19
Symptoms: Hypertension, Hypervolaemia, Increased viscosity of upper respiratory secretion, Inflammation, Infusion
Clinical narrative: Anemia, Elevated troponin, heart failure Chief Complaint   SOB x2 days, harsh cough. Brought in by rescue.  History of Present Illness     99-year-old male brought in via EMS for 2-day history of shortness of breath. Patient reports shortness of breath has been progressive, but got worse as he was not able to walk across room without breathing heavily. Per EMS, patient was 82% on room air, they did put him on 12 L and brought his oxygen up, they were away able to wean him down to 2 L. Patient reports that he has been coughing, though endorses chronic nasal congestion. States he was just in the hospital and hemoglobin was down to 6, needed to have a blood transfusion. Patient reports he did end up having iron infusion but is due for another 1. Denies any previous lung history or any positive contacts with known Covid or influenza. Patient does live in assisted living. He is up-to-date on his COVID 19 vaccine and booster and his influenza vaccine.   Per records review, patient was in the emergency department 12/11/2021 with similar symptoms of shortness of breath. Patient had elevated D-dimer, CT scan was without pulmonary embolus but did show emphysema scarring. Patient's hemoglobin was 6.7; he was transfused 2 units packed red blood cells and his hemoglobin came up to 8.5 and his symptoms improved.  Review of Systems     Constitutional: No fevers, chills, sweats  Eye: No recent visual problems  ENT: No ear pain, POS nasal congestion, No sore throat  Respiratory: POS shortness of breath, cough  Cardiovascular: No Chest pain, palpitations, syncope  Gastrointestinal: No nausea, vomiting, diarrhea  Genitourinary: No hematuria  Neurologic: Alert & oriented X 4  Physical Exam  Vitals & Measurements  T: 37  °C (Oral)  HR: 75(Monitored)  RR: 12  BP: 133/63  SpO2: 97%  HT: 174.000 cm  WT: 88.450 kg  BMI: 29.210  O2 Flow Rate: 2  O2 Therapy: Nasal cannula      General: Alert and oriented, pale-appearing, on nasal cannula 2 L, using accessory breathing muscles  Eye: PERRL, EOMI, normal conjunctiva; patient does not make eye contact (known macular degeneration)  HENT: Normocephalic, clear tympanic membranes, normal hearing, dry oral mucosa, no scleral icterus, no sinus tenderness.  Neck: Supple, no carotid bruits, no JVD, no lymphadenopathy.  Lungs: Mild coarseness throughout all lung fields, mildly labored respirations.  Heart: Normal rate, regular rhythm with frequent PVCs  Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no masses.  Musculoskeletal: Normal range of motion and strength, no tenderness or lower extremity swelling.  Skin: Skin is warm, dry and pink, no rashes or lesions.  Neurologic: Awake, alert and oriented X4, CN II-XII grossly intact.  Psychiatric: Cooperative, appropriate mood and affect.   DDx -  Severe anemia versus CHF exacerbation versus bronchitis versus pneumonia versus COVID-19 versus influenza among others?going to recheck CBC, troponin levels, proBNP as it does look like patient has had some elevations in these due to his severe anemia in the past. As he is requiring oxygen and has coarse breath sounds, we are going to get a chest x-ray, COVID 19/influenza; procalcitonin and CRP to investigate infectious causes and give him DuoNeb treatment to see if that helps with his symptoms.  1/4/2022 00:57:05    Assessment/Plan      1. Emphysema of lung J43.9   As fast as patient decompensated with his shortness of breath, actually favoring more of an emphysema exacerbation picture but in all fairness likely multifactorial.  Patient states he has never had any issues with his lungs, though on CT scan 12/11/2021 showed emphysema with scarring.  Scarring is also seen on his chest x-ray; this is stable.  His procalcitonin is negative, therefore not likely to have secondary bacterial infection.  We will try and be conservative and try 40 mg Solu-Medrol every 8 hours.  The DuoNeb did not seem to help his breathing, he is still requiring 2 L to maintain his oxygen sat.  We will keep these on board for as needed use.   2. CHF NYHA class III   proBNP is actually better than his last admission.  However, with patient's limited activity, would like to diurese patient to see if we can help with his breathing.  He is going to have a very delicate fluid balance and want to be very careful not to fluid overload him.   3. Shortness of breath   Emphysema versus heart failure versus the anemia?do feel that all of these are playing a role in his shortness of breath.  Would like to diurese patient before adding volume.  We will give him 20 mg Lasix IV now.  We will give him oxygen as needed.  Would like to be able to wean him off of oxygen, though he may require this going forward since he is unable to maintain blood level.   4. Iron deficiency anemia secondary to blood loss (chronic)    Patient's hemoglobin was 7.6.  As he is already slightly fluid overloaded, would like to wait until we can diurese for a few hours before giving him 1 unit packed red blood cells.  From what I can tell, patient likely lives around 8.0 so this should not be a significant shock to his system, though he will benefit from the blood.  Patient is scheduled for iron infusion outpatient on Thursday.  If patient happens to have a stool, will check for Hemoccult given his colon cancer history.  Last Hemoccult check at his previous admission was negative.   5. Nasal congestion   Patient uses nasal rinse and Flonase, still having nasal congestion that he reports has been going on for years but this is a complaint of his.  Since he has high blood pressure, would like to avoid pseudoephedrine.  Do question whether patient's symptoms are triggered by GERD.  We will try adding Protonix to see if that will help decrease inflammation although this will take several days to know if that is going to help.  We will give him some Mucinex to thin out his mucus as well as Claritin to try to decrease the amount of mucus that he is making.   6. High blood pressure     Orders:   Lasix, 20 mg = 2 mL, Soln, IV Push, As Directed, Routine, Start date 01/04/22 2:20:00 CST, 2 dose(s)/time(s), Physician Stop, 01/04/22 2:20:00 CST  Sodium Chloride 0.9% 250 mL, 250, mL, IV, Routine, Start date 01/04/22 2:20:00 CST, 1, dose(s)/time(s), Stop date: 01/05/22 3:19:00 CST, 10 mL/hr, 25, hr, Total volume (mL): 250, 88.45 kg, 2.07, m2, 01/04/22 2:20:00 CST  Blood Bank Product Request, Blood, 01/04/22 2:20:00 CST  Routine collect, 1/4/2022, 1, RBC, Low H&H, Hold Until Collected, No  Communication Order, 01/04/22 2:20:00 CST, May use Central or PICC Line or Port for blood administration and flush per policy  Hematocrit, Blood, Routine collect, 01/04/22 2:20:00 CST, Once, Stop date 01/04/22 2:24:00 CST, Lab Collect  Hemoglobin, Blood, Routine collect, 01/04/22 2:20:00 CST, Once, Stop date 01/04/22 2:24:00 CST, Lab Collect  Misc Nursing Task, Initiate Transfusion Reaction Order Set PMC, 01/04/22 2:20:00 CST, Initiate Transfusion Reaction Order Set PMC immediately when signs/symptoms of suspected transfusion reaction are identified in a patient, Once, 01/04/22 2:20:00 CST  Misc Nursing Task, Discontinue Blood Administration order set when blood complete., t;n, once, 01/04/22 6:20:00 CST, 01/04/22 6:20:00 CST  Obtain Consent, 01/04/22 2:20:00 CST, Confirm signed consent on chart  Peripheral IV Insertion, 01/04/22 2:20:00 CST, 18g catheter, may use smaller catheter if necessary  Transfuse Blood Products, 01/04/22 2:17:00 CST  Transfuse Blood Products PMC, 01/04/22 2:20:00 CST, Transfuse 1 unit of packed red blood cells.  Vital Signs, 01/04/22 2:20:00 CST, Obtain and chart T, P, R, BP & O2sat pre-transfusion, after start of transfusion @ 5min, 15min, 30 min, then q30min until transfusion is complete, and post-transfusion.  XR Chest 1 View Portable, 01/04/22 1:03:00 CST, Routine, 01/04/22 1:03:00 CST, SOB x2 days, No, Transport Mode: Wheelchair, , No, , Yes, Rad Type  Level 4     Images   Chest x-ray stable when compared to 12/11/2021; patient with cardiomegaly, stable scarring without any acute cardiopulmonary process appreciated by my read.  Await official.