Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Oxygen saturation decreased, Pain in extremity, Physical deconditioning, Platelet count normal, Pleural effusion
Clinical narrative: Pfizer Dose 1 1/25/21 Pfizer Dose 2 2/15/21 COVID Positive 9/9/21    Chief Complaint   shortness of breath  History of Present Illness    Patient is a 72 year old male, a resident of Senior Living Facility, who presented to ED via EMS with complaints of difficulty breathing.  Patient has a past medical history significant for atrial fibrillation, on chronic anticoagulation, hypertension, hypothyroidism, suspected obstructive sleep apnea, morbid obesity, venous stasis, and systolic heart failure with preserved ejection fraction LVEF 55%. He does not wear oxygen at baseline. He reports feeling short of breath with activity yesterday. His shortness of breath worsened today, he was short of breath at rest. He was unable to catch is breath and EMS was called. He also complains of left inferior leg pain, worse than normal. He endorses redness and swelling. He denies chest pain. No recent fevers. No nausea or vomiting. Denies being around ill contacts. Normal appetite.  On arrival to ED patient was hypertensive 153/96 and hypoxic on room air at 84%.  Supplemental oxygen was applied at 3 L with improvement in oxygen saturation 96%. Laboratory findings were significant for ALP 125. ProBNP 943. PH 7.46.  D-dimer 0.54.  CT chest negative for PE. Small left-sided pleural effusion with moderate atelectasis/partial collapse of the bilateral lower lobes.Chest x-ray showed mild pulmonary venous congestion. IV Rocephin and Zithromax were initiated in ED.  Patient received DuoNeb treatment.  Review of Systems    Review of Systems negative except as noted in HPI  Physical Exam Vitals & Measurements T: 97.2  °F   HR: 93(Peripheral)  RR: 20  BP: 135/102 SpO2: 96%  HT: 185.4 cm  WT: 146.8 kg     Constitutional:  Alert, no acute distress Head: Atraumatic, normocephalic. Eyes: Sclera anicteric, intact extraocular muscles Neck: supple, trachea midline, no JVD CVS:  Irregular rhythm, irregular rate, no murmurs or gallops Chest:  Decreased breath sounds in the lower lung bases bilaterally, slightly labored at 96% on 3 L NC, oxygen saturation decreases into mid 80s while patient is sleeping Abdomen: Soft, nontender, nondistended, normal bowel sounds in all quadrants. Neuro:  Alert and orientated x3. no focal neurological deficits observed MSK: free range of motion, no joint swelling Skin:  Chronic stasis dermatitis in lower extremities bilaterally, 2+ edema, left worse than right with increased erythema Psych:  Cooperative, appropriate mood and affect  Assessment/Plan     Assessment/Plan:  Acute hypoxemic respiratory distress likely secondary to pneumonia versus COVID-19 infection versus left-sided pleural effusion verses collapse of bilateral lower lobes  -empiric antibiotic treatment with IV Rocephin and Zithromax  -follow-up on blood cultures  -obtain sputum culture  -repeat ABG  -consult pulmonology  -respiratory therapy to evaluate and treat, supplemental oxygen as needed to maintain oxygen saturations greater than 92%, continuous pulse oximetry monitoring, Acapella and bronchodilator with albuterol HFA pending COVID result  -CPT bid   Atrial fibrillation on chronic anticoagulation  -continue Xarelto  Continue metoprolol  -apply telemetry   Systolic heart failure with preserved ejection fraction LVEF 55%  -strict I's and o's and daily weights  -continue home Lasix and potassium supplement  -sodium restricted diet  -most recent echocardiogram 2/21   Rule out Covid-19  -follow up on Covid results   Left inferior leg pain  -Wound care consult   Deconditioned  -physical therapy and occupational therapy to evaluate and treat  -social service consult for discharge planning needs   Hypothyroidism  -continue with levothyroxine dose   Full code  SCDs and Xarelto for DVT prophylaxis   APRN   Patient is at moderate risk developing complications related to hospitalization.  Estimated length of stay is greater than 2 midnights.  Problem List/Past Medical History  Ongoing (HFpEF) heart failure with preserved ejection fraction  Atrial fibrillation  BMI 40.0-44.9, adult  Chronic anticoagulation  Chronic Osteoarthritis( | Confirmed | )  Debility  HTN (Hypertension)( | Confirmed | )  Hypomagnesemia  Hypotension  Hypothyroidism, unspecified  Morbid obesity  Multiple falls( | Confirmed | )  Polyneuropathy( | Confirmed | )  Suspected sleep apnea  Venous stasis  Historical Other specified personal risk factors, not elsewhere classified  Proximal leg weakness( | Confirmed | )  Reviewed  Procedure/Surgical History ?Colonoscopy (06/06/2008) ?Colonoscopy (2008) ?Hx of total hip arthroplasty ?S/P TKR (Total Knee Replacement) ?S/P Carpal Tunnel Release  Reviewed  Medications  Inpatient No active inpatient medications  Home cholecalciferol 1000 intl units oral capsule, 1000 International Units= 1 Cap, PO, Daily (Once Daily)  compression hose- bilat, See Instructions  docusate sodium 100 mg oral capsule, 100 mg= 1 Cap, PO, BID (Twice Daily), PRN  furosemide 40 mg oral tablet, 60 mg= 1.5 Tab, PO, Daily (Once Daily)  guaiFENesin 400 mg oral tablet, 400 mg= 1 Tab, PO, BID (Twice Daily)  hydrocortisone 10 mg oral tablet, 20 mg= 2 Tab, PO, BID (Twice Daily), 6 refills  levothyroxine 100 mcg (0.1 mg) oral tablet, 100 mcg= 1 Tab, PO, Daily (Once Daily)  magnesium oxide 400 mg (240 mg elemental magnesium) oral tablet, 400 mg= 1 Tab, PO, Daily (Once Daily)  metoprolol tartrate 25 mg oral tablet, 25 mg= 1 Tab, PO, Q12Hours  midodrine, 10 mg, PO, TID (Three Times Daily)  Milk of Magnesia susp, 30 mL, PO, HS (At Bedtime), PRN  Nasal Saline 0.65% spray, 2 spray, Nostrils-Both, QID (Four Times Daily), PRN  polyethylene glycol 3350 oral powder for reconstitution, 17 gm, PO, Q72Hours-Interval  potassium chloride 10 mEq oral capsule, extended release, 20 mEq= 2 Cap, PO, Daily (Once Daily)  rivaroxaban 20 mg oral tablet, 20 mg= 1 Tab, PO, WEM (With Evening Meal), 3 refills  shower chair, See Instructions  Tylenol, 650 mg, PO, Q6Hours, PRN  Wheelchair - XL Size, See Instructions  Reviewed  Allergies  Latex (rash)  Reviewed  Social History   Alcohol   Past, 1-2 times per year, 12/16/2020   Current, 1-2 times per month, 10/03/2017   Employment/School   Retired, Work/School description: part time cleaning service, 2001., 10/03/2017   Exercise - Does not exercise, 06/05/2012   Home/Environment   Marital status: Married (Living together). Spouse/Partner name:. Lives with Spouse. 1 children. Living situation: Home/Independent. Home equipment: Walker/Cane., 10/03/2017   Nutrition/Health   Caffeine intake amount: 4-5 coffee per day., 06/05/2012   Other   active driving status, 10/03/2017   Substance Abuse - Denies Substance Abuse, 06/05/2012   Never, 10/03/2017   Never, 07/22/2015   Tobacco - Denies Tobacco Use, 06/05/2012   Never (less than 100 in lifetime), 10/03/2017   Never smoker, 07/22/2015  Reviewed  Family History  CVA - Cerebrovascular accident: Father.  Dementia: Mother.  Heart disease: Mother.  Hypertension: Father.  Other: Mother and Brother.  Reviewed  Immunizations   Vaccine  Date  Status  Comments   SARS-CoV-2 (COVID-19) mRNA BNT-162b2 vax 02/15/2021 Recorded SARS-CoV-2 (COVID-19) mRNA BNT-162b2 vax 01/25/2021 Recorded influenza virus vaccine, inactivated 10/15/2020 Given Verified by: NCMA influenza virus vaccine, inactivated 09/30/2019 Given verified influenza, unspecified formulation 01/01/2019 Recorded influenza virus vaccine, inactivated 10/01/2017 Given influenza virus vaccine, inactivated 09/01/2016 Given influenza virus vaccine, inactivated 12/18/2015 Given pneumococcal 13-valent vaccine 12/18/2015 Given influenza virus vaccine, inactivated 12/16/2014 Given influenza virus vaccine, inactivated 12/10/2013 Given pneumococcal 23-valent vaccine 12/10/2013 Given influenza virus vaccine, inactivated 10/04/2012 Recorded  Reviewed  Lab Results  Labs (Last four charted values) WBC      5.04   (SEP 09) Hgb      14.5   (SEP 09) Hct      44.1   (SEP 09) Plt      185   (SEP 09) Na      138   (SEP 09) K      3.8   (SEP 09) CO2      29   (SEP 09) Cl      99   (SEP 09) Cr      L 0.64   (SEP 09) BUN      12   (SEP 09) Glucose Random        86   (SEP 09) Ca      9.6   (SEP 09) PT      H 12.5   (SEP 09) INR      H 1.2   (SEP 09) Troponin        0.01   (SEP 09) ALT: 27 International Units/L (09/09/21 05:38:00)  AST: 34 International Units/L (09/09/21 05:38:00)  Diagnostic Results (09/09/2021 10:29 CT Chest for Pulmonary Emboli w C) IMPRESSION:  1. No evidence of pulmonary thromboembolic disease.  2. Small left-sided pleural effusion with moderate atelectasis/partial collapse of the bilateral lower lobes and dependent atelectasis of the bilateral upper lobes.  3. 4.2 cm fusiform enlargement of the ascending thoracic aorta, unchanged compared to the prior exam. [1] (09/09/2021 07:07 CDT Port Chest 1) IMPRESSION:  1. Moderate pulmonary venous congestion.  2. Likely tiny volume left pleural effusion.  3. Bibasilar airspace disease which may represent edema or atelectasis.  Correlate with symptoms of infection to rule out infiltrate. [2]    [1] CT Chest for Pulmonary Emboli w C; MD, 09/09/2021 10:29  [2] Port Chest 1; MD, 09/09/2021 07:07   Signature Line  Electronically Signed By: ARNP,  On 09.09.2021 01:09 PM  Electronically Signed By:   Addendum by MD, on September 09, 2021 16:57:41 (Verified)    Patient was personally independently seen and examined by me, staffed with APRN and agree with assessment and plan except as noted below.  72-year-old long-term resident of Nursing Home, fully vaccinated against COVID-19 who presents with worsening shortness of breath, cough and increasing sputum production since yesterday.  He reports positive contact at the nursing home with resident diagnosed with COVID-19 infection.  Was brought into the emergency department where chest CT demonstrated bilateral lower lobe collapse/atelectasis, hypoxic requiring initiation of supplemental oxygen via nasal cannula. COVID-19 PCR was subsequently positive following negative rapid antigen test.  Physical examination reveals a morbidly obese man, tachypneic and dyspneic, coarse breath sounds bilaterally with diminished breath sounds in lung bases, heart sounds are 1 and 2 and regular, abdomen obese but benign, extensive venous stasis changes in bilateral lower extremities with trace to 1+ pitting pedal edema, neuro nonfocal. He has been admitted to the hospitalist service home be started on treatment with antiviral therapy IV remdesivir, IV Decadron, empiric antibiotic therapy, supplemental oxygen as needed to keep oxygen saturation greater than 90% and wean down to room air as indicated, supportive care with antipyretics, mucolytics, antitussives as needed.  CPT/PD with incentive spirometry.  Pulmonary has been consulted, follow for further input and recommendations.  Monitor inflammatory markers.   Discharge Diagnosis COVID-19 infection  Bilateral community-acquired pneumonia, viral in etiology  Acute hypoxic respiratory failure, resolved Bibasilar lung collapse/atelectasis likely secondary to mucus plugging  Chronic atrial fibrillation on therapeutic anticoagulation  Acute exacerbation of heart failure with preserved ejection fraction  Hypothyroidism   Hospital Course  Procedures (09/09/2021 10:29 CT Chest for Pulmonary Emboli w C) EXAM:   CT ANGIO CHEST FOR PULMONARY EMBOLI W C [1] (09/09/2021 10:29 CDT CT Chest for Pulmonary Emboli w C) IMPRESSION:  1. No evidence of pulmonary thromboembolic disease.  2. Small left-sided pleural effusion with moderate atelectasis/partial collapse of the bilateral lower lobes and dependent atelectasis of the bilateral upper lobes.  3. 4.2 cm fusiform enlargement of the ascending thoracic aorta, unchanged compared to the prior exam. [2]    72-year-old man who presented with acutely worsening shortness of breath.  In the ED he was noted to be hypoxic to 84% on room air, elevated D-dimer was noted on account of which CT pulmonary angiogram was done and revealed bilateral lower lobe collapse and atelectasis.  COVID-19 PCR was subsequently positive.  Was admitted to the hospitalist service and started on pulmonary clearance measures were CPT/PD, self suctioning, bronchodilators and mucolytics.  He met criteria for treatment for COVID-19 infection on account of hypoxia and so was started on IV Decadron and remdesivir.  Hospital course was then complicated by acute exacerbation of heart failure on account of which diuresis was maximize with IV Lasix.  Clinical response was favorable with gradual improvement in oxygen requirements and patient has now been successfully weaned to room air.  He has been discharged in stable medical condition to long-term custodial care to continue outpatient follow-up.   Physical Exam Vitals & Measurements T: 35.7  °C (Tympanic)  T: 96.2  °F   TMIN: 94.8  °F TMAX: 35.7  °C (Tympanic)  HR: 83(Peripheral)  RR: 20  BP: 133/89 SpO2: 93%     GEN:_ alert, no distress, morbidly obese  LUNGS:_ coarse breath sounds with diminished lung bases, no crackles or wheeze  CVS:_ heart sounds are 1 and 2, regular, no murmur  VASCULAR:_  no carotid bruit, no palpable abdominal pulsations  ABD:_ full, soft, no areas of tenderness, normal bowel sounds  EXT:_ bilateral venous stasis changes, 1+ edema  NEURO:_ oriented, no focal neurologic deficits  SKIN:_ no rash or ecchymosis    Home Medications (20) Active  cholecalciferol 1000 intl units oral capsule 1,000 International Units = 1 Cap, PO, Daily (Once Daily)  compression hose- bilat See Instructions  dexamethasone 6 mg oral tablet 6 mg = 1 Tab, PO, Daily (Once Daily)  docusate sodium 100 mg oral capsule 100 mg = 1 Cap, PRN, PO, BID (Twice Daily)  furosemide 40 mg oral tablet 80 mg = 2 Tab, PO, Daily (Once Daily)  guaiFENesin 400 mg oral tablet 400 mg = 1 Tab, PO, BID (Twice Daily)  hydrocortisone 10 mg oral tablet 20 mg = 2 Tab, PO, BID (Twice Daily)  levothyroxine 100 mcg (0.1 mg) oral tablet 100 mcg = 1 Tab, PO, Daily (Once Daily)  magnesium oxide 400 mg (240 mg elemental magnesium) oral tablet 400 mg = 1 Tab, PO, Daily (Once Daily)  metolazone 2.5 mg oral tablet 2.5 mg = 1 Tab, PO, D14(Su,W)  metoprolol tartrate 25 mg oral tablet 25 mg = 1 Tab, PO, Q12Hours  midodrine 10 mg, PO, TID (Three Times Daily)  Milk of Magnesia susp 30 ml, PRN, PO, HS (At Bedtime)  Nasal Saline 0.65% spray 2 spray, PRN, Nostrils-Both, QID (Four Times Daily)  polyethylene glycol 3350 oral powder for reconstitution 17 gm, PO, Q72Hours-Interval  potassium chloride 10 mEq oral capsule, extended release 20 mEq = 2 Cap, PO, Daily (Once Daily)  rivaroxaban 20 mg oral tablet 20 mg = 1 Tab, PO, WEM (With Evening Meal)  shower chair See Instructions  Tylenol 650 mg, PRN, PO, Q6Hours  Wheelchair - XL Size See Instructions   Discharge Plan Discharged on up titrated dose of oral Lasix with the addition of metolazone.  Follow-up per primary care physician in 1 week.       Patient Discharge Condition Stable medical condition.  Discharge Disposition Discharge to long-term custodial care.  40 minutes were spent in coordinating patient's discharge.     Follow-Up       With  When  Contact Information        wound care Additional Instructions: Buttocks- Cleanse with saline. Apply Zgaurd paste three times daily and as needed   Reposition patient every two hours   Waffle cushion to chair            Additional Instructions:         Family Practice In 0 days - Senior Services     Additional Instructions: