Age: 83.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Intensive care, Lactic acidosis, Lung infiltration, Malnutrition, Nausea
Clinical narrative: co illness onset 9/24, fever, chills, nausea, loss of appetite & taste, HA, cough. dx w covid 9/26. 9/29 had monoclonal antibodies, then to ED in BV, and was discharged on O2. today PCP. last ibuprofen at 0800 History of Present Illness  Symptom onset 9/24 or 25, home test dx 9/26, then to ED - dxed, 9/29 monoclonal antibodies, sent home on O2. Went to PCP Dr. or least contacted him ?virtual visit? told to come to ED as pulse ox reading 80s despite being on oxygen  Fever, HA, cough, somewhat productive but swallows sputum so hasn;t seen it. Fully vaccinated w  Pfizer vaccine second shot in March. States had plans to get booster right before starting having these symptoms.        Assessment/Plan      1. Pneumonia due to COVID-19 virus    2. Acute respiratory failure with hypoxemia   symptom onset 9/25, s/p monoclonal antibodies, fully vaccinated second shot (Pfizer) in March, not received booster   will start Dex, RDSV, Baricitinib as has many risk factors for worsening and already increased O2 needs, on 15L  CXR looks more like left sided infiltrate and not severe at this point at least, repeat in am   3. Lactic acidosis   he appears dry, mild AKI, urine concentrated, start fluids w LR   4. CAD (coronary artery disease)   cont DAPT, statin   5. Hyperglycemia due to type 2 diabetes mellitus   start basal-prandial insulin as CBGs expected to go up more with Dex   6. Transaminitis   mild, not to where need to hold RDSV, baricitinib or statin but need followed     7. Thrombocytopenia    no old labs to compare, ?due to COVID, will cont DAPT with CAD but hold off on adding chemical vte prophylaxis - recheck CBC in am   Problem List/Past Medical History   CAD  HTN  Dyslipidemia  BPH Procedure/Surgical History  CABG - Coronary artery bypass graft Hernia Stent Medications  Inpatient  acetaminophen, 650 mg= 2 tab(s), PO, q4hr, PRN albuterl inhaler, 2 puff(s), Inh, q4hrWA aspirin, 81 mg= 1 tab(s), PO, Daily atorvastatin, 40 mg= 1 tab(s), PO, at bedtime baricitinib, 4 mg= 2 tab(s), PO, Daily clopidogrel, 75 mg= 1 tab(s), PO, Daily dexamethasone, 6 mg= 1.5 mL, IV Push, Daily Dextrose 50%, 25 Gm= 50 mL, IV Push, as needed, PRN Insulin Corrective Scale Low Dose, Corrective Dose Scale 0-8 Units, Subcut, acTID insulin glargine, 10 unit(s), Subcut, wBKF insulin lispro, 3 unit(s)= 0.03 mL, Subcut, wMeals LR 1,000 mL, 1000 mL, IV melatonin, 5 mg= 1 tab(s), PO, at bedtime ondansetron, 4 mg= 1 tab(s), PO, q8hr, PRN ondansetr Pharmacy Consult COVID ICU Fluid Restriction - PIV, 1 EA, Misc, as directed Once Remdesivir additive + Normal Saline 250mL 250 mL Remdesivir additive + Normal Saline 250mL 250 mL Remdesivir additive + Normal Saline 250mL 250 mL Saline FLUSH Peripheral, 2.5 mL, IV Flush, BID tamsulosin, 0.4 mg= 1 cap(s), PO, at bedtime Currently hospitalized on 10/12:Length of stay:  12      Total Critical Care Days: 11    Subjective  Chart reviewed.  Patient is alert.  He denies dyspnea.  He does describe a productive cough.  Taking p.o..  Patient does complain of anorexia.   .    Continued hospitalization due to: Current condition requires inpatient care.      Objective  VS/Measurements    Vital Signs( 10/11/21 14:05:12 to current )  VITAL SIGN LAST CHARTED MINIMUM MAXIMUM  Blood Pressure 104/67   (10/12 12:00) 97/45   (10/12 06:15) 151/78   (10/11 17:00)  Heart Rate 85   (10/12 12:00) 57   (10/12 03:00) 97   (10/12 08:30)  Respirations 28   (10/12 12:00) 17   (10/12 02:00) 42   (10/12 01:00)  Temperature 96.5   (10/12 12:00) 96.5   (10/12 12:00) 97.4   (10/11 20:00)  SpO2 100   (10/12 12:00) 84   (10/12 08:30) 100   (10/12 12:00)  Oxygen Flow Rate 70   (10/12 12:00) 40   (10/11 15:46) 70   (10/12 12:00)  Weight 79.6   (10/12 04:00) 79.6   (10/12 04:00) 79.6   (10/12 04:00)  ,   Weight Measurements Current Weight Last Weight Weight Difference 79.6 kg   10/12/21 04:00 80.2 kg   10/11/21 05:52  -0.600  Current Weight Admission Weight Weight Difference 79.6 kg   10/12/21 04:00 86 kg   10/01/21 13:59  -6.400   Intake and Output    I & O Summary - 24 Hour 0700-0659  Input:           10.50 ml  Output:          1150.00 ml  Balance:        -1139.50 ml Stool Count:               0  I & O Summary - Full Visit  Input:         8023.42 ml  Output:         18480.00 ml  Balance:       -10456.58 ml Stool Count:               2 ,   I & O Detailed Summary - 24 Hour 0700-0659  INTAKE  IV Volume Infused                               10.50 ml Total         10.00 ml  OUTPUT  Urine Voided                                  1150.00 ml Total       1150.00 ml  BALANCE:   -1139.50 ml  ,   I & O Summary - Full Visit  Input:         8023.42 ml  Output:         18480.00 ml  Balance:       -10456.58 ml Stool Count:               2     Physical Examination  General:  No acute distress.   Eye:  Normal conjunctiva.        Sclera: Not icteric.   HENT:  Normocephalic.   Neck:  Supple.        Trachea: Midline.   Respiratory:  Respirations are non-labored, Breath sounds are equal, Symmetrical chest wall expansion.        Breath sounds: No rhonchi present, No wheezes present.        Breath sounds: No crackles present.   Cardiovascular:  Normal rate, Regular rhythm, No murmur, No gallop, No edema, No Pericardial friction rub.   Gastrointestinal:  Soft, Non-tender, Non-distended, Normal bowel sounds.   Integumentary:  Warm, Dry.   Neurologic:  Alert, Oriented.   Psychiatric:  Cooperative, Appropriate mood & affect.     Review / Management  General Review:  Rhythm Strip.   Rhythm Strip Interpretation:  I personally reviewed the study, Sinus rhythm.   Ventilatory Support  Basic Oxygen Information  10/12/2021 12:00  SpO2 100 %  Oxygen Flow Rate 70 L/min  Oxygen Therapy Nasal cannula, Humidification  FIO2 100 % 10/11/2021 23:15  SpO2 96 %  Oxygen Flow Rate 60 L/min  Oxygen Therapy Nasal cannula, Humidification  FIO2 100 %   Laboratory Results:    Basic Chemistry Result            Sodium Level 136 mmol/L  (10/12/21)  Potassium Level 3.7 mmol/L  (10/12/21)  Chloride 92 mmol/L  (10/12/21) - Low  CO2 32 mmol/L  (10/12/21)  AGAP 12 mmol/L  (10/12/21)  BUN 43.9 mg/dL  (10/12/21) - High  Creatinine 1.1 mg/dL  (10/12/21)  BUN/Creat Ratio 40   (10/12/21) - High  eGFR 61 mL/min/1.73m²  (10/12/21)  Glucose Level 75 mg/dL  (10/12/21)  Calcium 9.1 mg/dL  (10/12/21) ,    ,   Basic Hematology Result            WBC 16.53 K/mcL  (10/12/21) - High  Hgb 15.2 Gm/dL  (10/12/21)  Hct 44.9 %  (10/12/21)  Platelet 225 K/mcL  (10/12/21) .        Microbiology: Blood Cultures  10/1/2021 15:54  NEG Blood Culture 10/1/2021 15:50  NEG Blood Culture .   Point of care testing:  Diabetic View (FS)  10/12/2021 11:13  POC Glucose 154 mg/dL  HI 10/12/2021 7:47  POC Glucose 87 mg/dL 10/12/2021 4:37  Glucose Level 75 mg/dL 10/11/2021 16:20  POC Glucose 343 mg/dL  HI .   Radiology results       X-ray: Diagnostic Radiology (FS) : Diagnostic Radiology  10/12/2021 6:25 CDT      XR Chest 1 View           Radiology Report  , I personally reviewed the study, Bilateral infiltrates either unchanged or slightly worse.  Medication Review:  Current Meds Reviewed, Home Meds Reviewed.   DVTProphylaxis:       Patient currently receiving: Lovenox.   GI Prophylaxis:       Patient currently receiving: Lansoprazole.   Education and Follow-up:       Counseled: Patient.   Early Progressive Mobility Protocol (EPMP):    EPMP Level: Level 3.   Nutrition  PO  Nutrition ADLs  10/12/2021 12:00  Diet Type dental soft 10/12/2021 8:00  Breakfast Percent 15 %     Nutrition Recommendations  Malnutrition Diagnosis  Malnutrition Severity: severe (10/11/21) Context: acute illness/ injury (10/11/21) Related to: poor appetite, respiratory status, early satiety (10/11/21) As evidenced by: unintended wt loss (10.9% x ~17), average intakes intakes provided <50% x1 wk prior to admit, skeletal muscle depletion (mild- 1 areas, moderate- 3 areas), subcutaneous fat loss (mild- 1 area), (10/1-10/1) avg provided 22% energy and 16% est protein needs (10/11/21) Progress: worsened (10/11/21)  Dietitian Recommendations  Oral 1: dental soft chopped, NCS, NAS (10/11/21) Supplement 1: Smoothie @ breakfast and dinner (10/11/21) Supplement 2: old fashioned shake @ lunch (10/11/21) Enteral 1: EN indicated as of 10/6, will be at refeeding risk. (10/11/21) Enteral 2: RD available PRN for recs if indicated MNT desired. (10/11/21) Enteral 3: . (10/11/21) Parenteral 1: TPN indicated if unable to obtain EN access as of 10/6 (10/11/21) Parenteral 2: . (10/11/21) Parenteral 3: . (10/11/21)    Impression and Plan  Diagnosis:  Pneumonia due to COVID-19 virus.        Course: Baricitinib day 9 of 14.  Remdesivir day 5 of 5. Dexamethasone day 10 of 10.        Plan: Continue to support.    .   Diagnosis:  Acute respiratory failure with hypoxemia.        Plan: Titrate O2 as we are able.  Encourage self proning.  .   Diagnosis:  Hyperglycemia due to type 2 diabetes mellitus.        Plan: Sliding scale insulin  .   Diagnosis:  Transaminitis.        Plan: Most likely viral (COVID) induced  .   Diagnosis:  CAD (coronary artery disease).        Plan: ASA, Plavix, EF 70%.  Probable diastolic dysfunction  .   Diagnosis:  COPD.        Plan: Scheduled bronchodilators  .   Diagnosis:  Severe protein calorie malnutrition.        Plan: Encourage p.o. intake  .   Diagnosis:  Over weight BMI -26.        Course: Unchanged,    .        Orders:   Addendum: I discussed resuscitation status with the patient.  He wishes to discuss this with his wife.  We will speak again tomorrow..