Age: 54.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Acute respiratory failure, Blood creatinine increased, Breath sounds abnormal, Bronchoscopy abnormal, C-reactive protein increased
Clinical narrative: Patient hospitalized 8.7.21 - 8.12.21 for COVID-19 (fully immunized); now readmitted for respiratory failure (COVID-19) 8.21.21 - present  DETAILS OF 1st HOSPITAL STAY:  PRESENTING PROBLEM: Pneumonia due to COVID-19 virus  HOSPITAL COURSE: Patient is a 55 y.o. male  s/p renal transplant (2017) on immunosuppressive therapy, s/p CABG (2018), T1DM on insulin pump, and PAD who presented to the ED on 8/9 with fever, nonproductive cough, body aches, nausea, and diarrhea since 8/3 after attending a wedding   Emergency department patient was afebrile, mild tachycardia 100, initially saturating well with PO2 >96% but with intermittent desaturations near 90% at rest, placed on 2L NC as needed. He was given 500 cc bolus of NS. Chest Xray showed no evidence of infiltrate. Mild hyperkalemia at 5.1, Cr of 1.5. No leukocytosis, but COVID19 positive. Patient was admitted for Covid19 Pneumonia with close monitoring due to high risk status for poor outcome. On the floors patient continued to be intermittently hypoxic with worsening chills and body aches and nonproductive cough. Trended D-dimers 1060, 950, 840; and CRP 13.6, 21.3, 53.1. Given patient's mild symptoms and high risk status Infectious Disease was consulted and started patient on Remdesivir. Patient's o2 saturation remained stable for the first day, but began showing persistent hypoxia with desaturations to 88% at RA with exertion, and was started on 1L NC. Infectious Disease recommended patient begin 10 day course of Decadron with the advent of acute hypoxic respiratory failure necessitating 1L NC to prevent desaturations. Patient also was granted "compassionate consideration" and received inpatient monoclonal antibody infusion on 8/12. Patient's symptoms gradually improved and was weaned of supplemental oxygen by 8/11. Patient was medically and vitally stable for discharge home on 8/12/21 with 6 days of decadron. Nephrology was consulted to assist with patient's immunosuppression medication and delicate renal status. They recommended reducing tacrolimus to 1mg BID and cellcept to 250mg BID after trending elevated trough levels while inpatient. Patient recommended to continue reduced doses until he follows up with his transplant clinic within 1 week for dose adjustments. Patient experienced steroid induced hyperglycemia and his insulin pump was managed by consult with setting changes. He was found to be in the 300's during the evenings and 100's in the mornings. He will need to follow up after discharge as he completes his final decadron dose on 8/18/21 to readjust his insulin pump settings to prevent hypoglycemia.    Current hospitalization:   Principal Problem:   Respiratory failure with hypoxia Active Problems:   Type 1 diabetes mellitus with stage 3a chronic kidney disease, retinopathy (bilateral nonproliferative without macular edema), polyneuropathy   Pneumonia due to COVID-19 virus   Pneumonia of both lower lobes due to methicillin susceptible Staphylococcus aureus (MSSA)    Hypotension   Acute deep vein thrombosis (DVT) of brachial vein of left upper extremity   Difficult airway for intubation Brief exam: Intubated, sedated, breath sounds coarse, minimal edema Brief History and Medical Decision-Making: 55 y.o. with emphysema who had COVID-19, now complicated by MSSA pneumonia and cavitary pneumonia of left lower lobe.  Concern for fungal pneumonia bc of elevated BAL galactomannan but no positive cultures.  Appreciate ID input regarding antibiotics.  Karius relatively unhelpful.  Therapeutic/diagnostic bronch 8/30 given worsening CXR, concern for mucus plugging.