Age: 54.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Acute respiratory failure, Anxiety, Blood culture negative, COVID-19, Chronic obstructive pulmonary disease
Clinical narrative: Patient with history of 2 COVID vaccines who admitted with detected COVID PCR.  Provider d/c note: "Patient is a 55 y/o woman with a hx of severe COPD/emphysema, chronic hypoxic resp failure on 2-3 liters of home O2 daytime and iVAPS at night, former smoker (35 pack/year), osteoporosis who developed worsening SOB with increased cough and sputum production on 12/5/22. She presented to the ED via EMS on 12/6/22 and was admitted with COPD exacerbation. She tested negative for COVID and influenza on 12/6/22. Pt was treated with azithromycin, solumedrol, bronchodilators, inhaled steroids and BiPAP.  Respiratory status worsened despite treatment. On 12/8/22 she was transferred to CCU and was intubated and mechanically ventilated. Viral panel was re-checked and pt found to have influenza A.    During her stay in CCU the following problems were addressed:   Acute on chronic respiratory failure  Underlying severe emphysema Influenza A + Intubated 12/8/22 and required sedation for vent tolerance. Bronchodilators and inhaled steroids, systemic steroids continued.  Influenza A treated with tamiflu.  Tolerated SBT and was extubated to BiPAP on 12/13/22, but failed extubation and required reintubation 12/14/22. Ongoing discussions were held with pt and family re: goals of care.  Pt had been evaluated for lung transplant but was not actively on list. Pt discussed with transplant team who stated that pt would only be transplant candidate following trach and improved strength, likely 3-4 years out.  Pt and family chose to continue aggressive care and mechanical ventilation and opted for trach/PEG which was placed 12/22/22. Since that time pt has been on AC/PC vent with daily SBT which she tolerates for ~2 hours daily.  Systemic steroids have been weaned down - current prednisone dose 20mg/day.  Circulatory shock Required intermittent BP support with norepi while deeply sedated.  Consistently normotensive the past several days.  Sinus tachycardia Persistent throughout hospitalization. Thought to be due to severe underlying lung disease, anxiety  Anxiety/depression Initially treated with propofol/fentanyl/precedex gtts Now on home celexa, seroquel and klonopin with adequate control  Required long precedex wean and clonidine added for precedex withdrawal  Severe protein/calorie malnutrition  Maintain in TFs throughout stay and is tolerating  Fusobacterium nucleatum bacteremia Completed course of ceftriaxone and flagyl with subsequent negative blood cultures.  ID recommended  further investigation pancreatic lesion with MRI and colonoscopy as this organism typically comes from mouth or GI, maybe associated with malignancy in the GI tract and thrombosis.  (CT done on 12/9/22 showed Low-attenuation lesion within or adjacent to the pancreatic tail) Stress/steroid hyperglycemia Controlled with SS insulin    On day of discharge pt is awake and alert. Reports feeling anxious about discharge.  Blood pressure 114/73, pulse 120, temperature 37.1 °C (98.8 °F), resp. rate 27, height 1.702 m (5' 7.01"), weight 54.5 kg (120 lb 2.4 oz), SpO2 97 %.  Remains on AC/PC vent with good sats and mildly increased work of breathing at rest which is baseline for pt. Abd soft and PEG 4 cm at skin. TF being held for transport. Extremities warm, no edema and palpable.  Stable for transport. Family aware of discharge today.