Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: Confusional state, Cough, Device connection issue, Encephalopathy, End stage renal disease
Clinical narrative: on HD MWF, L RCC s/p nephrectomy 3/2014 with recurrent CA metastatic to pancreas, h/o PE 11/2020 on Eliquis, hypothyroidism, AAA, recurrent urinary retention with chronic foley (last changed by HHRN 11/13/21, and changed here 11/29 due to foley bag disconnection issue), OSA on CPAP, and emphysema seen on CT (no PFTs on file), uses home O2 on 2 liters, uses intermittently, presented with increased cough, wheezing around 11/21/21, tested positive for COVID (outside of facility 11/23). Family feel his symptoms started on 11/17. Pt was vaccinated with moderna, second dose completed April 21, 2021, has not had booster yet.  Pt was brought to ED by family on 11/26 due to worsening fatigue, wheezing and lower than baseline O2 sat since COVID infection.  In ED O2 sat 86% on RA on arrival, improved to low 90s, CXR showed diffusely coarsened lung markings and patchy LLL opacity, consider atypical pneumonia including COVID 19 pneumonia.      COVID-19 pneumonia COPD exacerbation Acute on chronic hypoxemic respiratory  COVID symptom onset on 11/17/21 per family. COVID positive on 11/23. Afebrile since admission.  Since admission O2 requirement has increased from 2 to 4 lpm, chest tight and diffusely wheezes likely due to COPD exacerbation triggered by COVID infection per pulmonary. Pt received prednisone 40 mg on 11/26.  - Pulmonology recommended high dose steroid solumedrol 125mg q6hrs and reassess daily. Started on 11/27 with improvement. Given hyperglycemia and intermittent confusion possibly due to steroid related encephalopathy, we did quick tapering. Changed solumedrol to 60 mg q6hr on 11/28, tapered to 40 mg q12hr 11/29-30. tapered to prednisone 40 mg daily 12/1-2. Case discussed with another physician today 12/2, who suggested to switch back to decadron 6 mg daily for another 3 more days to complete a total of 10 days (11/26-12/5) - Pt not candidate for Remdesivir due to ESRD.  Per discussion with pulm, pt is not candidate for Toci or Baricitinib due to abnormal LFTs when admitted. Pt is improving with steroids.  - supplemental O2 to keep O2 sat >92%. On 2L NC at baseline  - pepcid for GI prophylaxis when on steroids  - trend inflammatory markers: CRP 1.1->0.9->0.6. d dimer 2.95->2.55 - combivent MDI prn  - cont HD to keep on negative side - continue isolation in hospital per Regulatory Authority guidance. Likely will need isolation until 12/6 (3 weeks after symptom onset on 11/17) - pt is on apixaban for h/o PE    Abnormal LFTs- likely due to COVID infection. transaminitis with elevated alk phos.  Tbili wnl.  RUQ u/s without biliary obstruction, gallstones or generalized BG wall thickening.  No abdominal pain on exam.  Improving with ALT 293->184->125->81->54 -hold PTA statin. Will resume on discharge as liver function is improving  -follow LFTs Encephalopathy likely multifactorial from COVID infection and steroids. Pt also had elevated liver enzymes, hyperglycemia, uremia from ESRD. No sign of central infection. Improving.  - tapering steroids quickly as pt's O2 saturation has been stable.   - monitor glucose - monitor liver enzymes improving  - on dialysis for ESRD - appreciate PT eval: No PT needs  - mentation improved    DM -poorly controlled per last a1C 10.1 in 6/2021. Repeat Hba1c 9.6. Was on NPH 18+20 units at home. hyperglycemia likely due to steroids   - increased NPH to 25 units BID. Continue PTA regular insulin 4 units bid AC. - will continue home dose on discharge as we will taper off steroids in 3 days  - diabetes education    ESRD on HD MWF - Cont routine HD MWF in hospital Given COVID status, pt will have dialysis in another facility with TTS 6 am until out of isolation  Appreciate nephrology follow up and arrange for dialysis  Pt received dialysis today 12/2 Thursday to prepare to start dialysis on Saturday.  Appreciate PCC arranging transportation for dialysis on Saturday