Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram thorax abnormal, Condition aggravated, Haemoglobin decreased, Haemoptysis, Hypothyroidism
Clinical narrative: Assessment and Plan Patient is a 75 y.o. female patient of No, Physician with history of recent admission for AHRF discharged on 10/9, CKD, chronic debility, PE, bipolar disorder presented to Hospital with low hemoglobin, found to be hypoxic, PNA seen on CT, and tested positive for COVID   Acute Respiratory Failure with hypoxia suspect 2/2 COVID Chronic hypoxic respiratory failure on 2L baseline COPD with acute exacerbation Covid-19 Virus Infection (vaccinated) Hx of PE  Hypoxia on presentation and placed on HFNC. Resolved Afebrile and no leukocytosis.  Mild tachypnea. VBG: 7.41/40.5/36.  Lactic acid 2.3, repeat WNL CT chest showed bibasilar, L>R atelectasis/consolidation, LLL pneumonia  Repeat CXR on 10/26 showed improved aeration of LLL base with residual bibasilar opacities still present  Neg strep, legionella, respiratory PCR, sputum culture. BC x2 NGTD MRSA nare positive, unclear clinical significance. Off abx  Pulm believes prior de-sat d/t mucus plugging, improved with pulmonary hygiene  Wean supplemental O2 as tolerated, goal SpO2- 88-92% Patient on 2L O2, at baseline. Breathing treatments, chest physiotherapy  Continue decadron for COVID, switch to PO; 10 day course completed ID consulted, completed remdesivir 10/27 Patient refusing DC back to SNF, will need SW assistance 10/30.  No other SNF accepting pt, plan to dc back to SNF today. Medically stable for dc home   Acute on chronic macrocytic anemia- stable  Hemoptysis, mild- resolved  Multifactorial anemia including iron deficiency and CKD Currently on eliquis for PE, held at this time  Hemoglobin on admission 6.8, baseline ~ 7-8 S/p 1u pRBC 10/21, repeat Hgb adequate response Monitoring hemoglobin to goal> 7 Team discussed blood products with patient in depth 10/26, agreed for blood if needed  Pulm did not believe hemoptysis is contributing to anemia significantly IV Fe x2; transition to PO iron, would benefit from colonoscopy outpatient vs inpatient if further bleeds No signs of hematochezia, melena, will continue PO PPI Will closely monitor for any other signs of overt bleeding Patient not having labs drawn although ordered    Elevated troponin, suspect 2/2 demand ischemia in setting of hypoxia, acute blood loss anemia, poor clearance in setting of CKD Chronic HFpEF  Continue home bumex to maintain euvolemia    CKD stage III/VI- Cr continues to be below baseline  Lactic Acidosis on admission- resolved  Creatinine on admission 2.38.  Baseline creatinine 2.4?2.5 Currently below baseline, 1.7 today  Renally dose medication, avoid nephrotoxins   Hypothyroidism Last TSH 12.55 on 10/6/2023  Continue home Synthyroid, repeat TSH in 4 to 6 weeks from last   Chronic pain Continue Flexeril, gabapentin, tramadol   Physical debility Per chart review, patient has been nonambulatory for several months Patient has had several hospitalizations Continue PT OT, dc back to SNF   Bipolar disorder Schizoeffective disorder Continue Seroquel 25 mg every morning and 50 mg q. nightly Continue doxepin, Depakote BH consulted for reported suicidal ideation. Has since been cleared from precautions    GERD Esophagitis Per chart review from last admission, CT showed mild diffuse circumferential thickening of the esophageal wall which can be associated with an esophagitis or sequelae of chronic GERD EGD from 2016 with ulcers. Continue PPI   Obesity class I Body mass index is 32.26 kg/m². Lifestyle education