Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Chronic obstructive pulmonary disease, Coagulation test, Condition aggravated, Cough, Depression
Clinical narrative: Chief Complaint   Pt seen earlier tonight but left AMA at 0200. Pt checking back in for increased work of breathing and SOB.  History of Present Illness     This is a 67 y/o male with history of COPD (baseline 5L NC), CAD s/p CABG/multiple PCI (most recent PCI May 2021), recurrent Vtach s/p ICD, HFpEF, DMT2, obesity, OSA who presents with 4 days of worsening dyspnea, cough, and diarrhea (sx onset 12/23).  Tested positive for COVID 12/26 in ED.  Is triple vaccinated against COVID.  At time of exam, was requiring 75% FiO2 35L.  Feels less short of breath now.  Admits to some subjective fevers at home.  Normally is able to walk to other room without dyspnea, but not up stairs.  Prior to admission, says he had been feeling short of breath at rest also.  Review of Systems     Constitutional: +fever  Skin: No rashes or lesions.  Eye: No visual problems  ENT: No ear pain, sore throat, or nasal congestion.  Resp: +cough +shortness of breath  CV: No chest pain.  GI: No abdominal pain. +diarrhea  GU: No dysuria or hematuria.  MSK: No back pain.  Neuro: No headache. No numbness/tingling/weakness.  Psych: No anxiety.    All systems otherwise negative. ROS reviewed as documented in chart.  Physical Exam  Vitals & Measurements  T: 36.6 °C  TMIN: 36.3 °C  TMAX: 36.6 °C  HR: 86  RR: 8  BP: 158/82  SpO2: 94%  WT: 126 kg  BMI: 42.6      General Appearance: large body habitus, lying in bed, no acute distress  HENT: Normocephalic, atraumatic. No nasal discharge.  Moist mucous membranes.  Neck is supple, midline trachea.  Eyes: PERRL, EOMI. No conjunctival injection, discharge, or periorbital edema.  Cardiac: RRR, S1 and S2 present without murmurs.  No peripheral edema. Good peripheral perfusion.  Respiratory: Mild bilateral rhonchi. Symmetrical chest expansion, good respiratory effort.  Abdomen: BS +, soft, nontender.  MSK: No significant deformity or edema. Peripheral pulses intact.  Neuro: CN II-XII grossly intact. Alert, no focal deficits.  Skin: No rashes, lesions, or eruptions.  Psych: Appropriate affect, cooperative.  Assessment/Plan      This is a 67 y/o male with history of COPD (baseline 5L NC), CAD s/p CABG/multiple PCI (most recent PCI May 2021), recurrent Vtach s/p ICD, HFpEF, DMT2, obesity, OSA admitted to the hospital for acute hypoxic respiratory failure secondary to COVID-19 requiring high flow oxygen.  Triple vaccinated.  Sx onset 12/23.  + test 12/26.  Checking inflammatory markers.  Afebrile, no leukocytosis.  Treating with remdesivir, dexamethasone.  Neuro  #Depression  #Mood disorder  #Neuropathy  - Continue half dose home Abilify 5mg daily  - On very high home dose of Lyrica given renal function.  Will do 150mg bid here.  - Hold trazodone and venlafaxine  Pulmonary  #Acute hypoxic respiratory failure secondary to COVID-19  #COPD  - Inflammatory markers pending: procal, ferritin, LDH, ESR, CRP  - Dexamethasone 6mg daily (12/27-1/5)  - Remdesivir (12/27-12/31)  - Will decide on tocilizumab vs baricitinib pending inflammatory markers  - Get baseline ABG  - Sputum culture  - Doppler venous US of LE to r/o DVT  - Continue home bronchodilators  Cardiac  #CAD s/p CABG/stents  #Recurrent Vtach s/p ICD  #HFpEF  - Continue home bumex 6mg tid  - Continue home spirinolactone 25mg daily  - Continue plavix 75mg daily  - Continue half home dose carvedilol: 12.5mg bid  - Hold home chlorthalidone, lisinopril  - Continue atorvastatin  - Hold Eliquis, start heparin subcutaneous ppx  - Check PT/INR/PTT  Renal  #Chronic kidney disease, stage 3A (baseline Cr ~1.3-1.5)  - BMP pending  - Monitor electrolytes  GI  - Protonix ppx while on steroids  - Doc/senna prn, was having diarrhea on admission  Endo  #Diabetes mellitus type 2, insulin dependent at home  - On 58u basal insluin at home, will start on 40u here and likely need to increase with steroid use  - SSI for now, will adjust once he starts eating  ID  - Initially has no leukocytosis, afebrile  - Will obtain blood, sputum cultures  Heme/Onc  - No acute concerns    Dispo: SICU (on pulm service)  Diet: NPO  DVT PPx: heparin subcu  Code Status: Full  Patient staffed with attending physician Dr. (Privacy) Addendum by MD, (Privacy) on December 27, 2021 21:21:52 (Verified)    I saw and evaluated the patient. I discussed the management with the resident and the hospital Team. I reviewed the resident's note above and agree with the documented findings and plan of care with the following clarifications/additions:  67 yo male with  COVID 19 Pneumonia: vaccinated, sx of worsening dyspnea and GI symptoms  Acute on chronic Hypoxic resp failure requiring HFNC  COPD with severe obstruction  Chronic res failure on home O2  CAD S/P CABG, S/P Stents  S/P ICD  on AC with eliquis did not take doses yesterday  Baseline can walk to kitchen and back cant walk up stairs  Plan for repeat labs esp CMP, check coags, ABG, inflammatory markers then likely toci as rapid increase in fio2 requirements to HFNC, start dexamethasone and remdesevir, initiate dvt prophylactic dose heparin holding eliquis for now, PPI, reduce dose of home lyrica, hold trazodone and effexr for now, manage blood glucose levels with insulin, repeat CXR  cc time > 35 minutes