Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Hypophagia, Hypoxia, Infection, Inflammation, Interstitial lung disease
Clinical narrative: CHIEF COMPLAINT: Hypoxia/generalized weakness. HPI: This is a 70-year-old male with history of COPD O2 dependent with a baseline FiO2 requirement 4 L/min who resides at assisted care living and other past medical history significant for PE chronically on rivaroxaban, hyperlipidemia, morbid obesity, and sleep apnea who presents here for a third time within the last 4 days for weakness and hypoxia. Patient was initially seen in the ED on 1/18/2022 due to low O2 sats and weakness. He apparently slipped out of bed and was unable to get himself up.  911 was called. He was notably not wearing CPAP during that night. He was brought in and diagnosis of a urinary tract infection and work-up was generally unremarkable so he was discharged back to his usual prior living arrangement. He presented again yesterday as he slid out of bed blaming that the bed was stuck and would not adjust so that he could not get out in his usual manner. He states that he has a sleep number bed at home and it was dysfunctional and stuck so he tried getting up without the head being elevated enough. He was then brought again today for shortness of breath and hypoxia. He was noted to be hypoxemia with sats in the 60s so 911 was called. On EMS arrival, his sats were in the 60s and he was placed on a nonrebreather. This did improve his sats to the 90s and he was brought in for further evaluation. He reports a chronic nonproductive cough. Does use a CPAP for sleep apnea at night but has not been able to use it recently due to mask not fitting very well. Since arrival to the ED, they were able to bring his FiO2 requirements down to 6 L near to his baseline of 4 L. Basic labs are fairly unremarkable. Chest x-ray demonstrates reticular findings suggestive of interstitial lung disease/severe emphysema.  CT scan demonstrated bullous emphysematous changes with ground-glass bilateral opacities. There does appear to be a dense posterior right middle lobe consolidation concerning for pneumonia. Images were reviewed by myself. On my interview, patient states that he is feeling better but is frustrated and feels that assisted-living staff may be twisting his story a bit. FiO2 requirements are at 6 L. He denies any chest pain. I was asked to admit him for further inpatient cares. It is noted that his care facility has now refused to take him back right away and feels that he may benefit from a TCU stay prior to returning. Case manager worker note also appreciated. There has been some concerns that he has not been able to get out of bed and transfer independently with progressive weakness and intermittent worsening shortness of breath. Notably, patient consumes alcohol on daily basis but amount is unclear. PROGRESS NOTE 1/30/2022- Pulmonary: Acute hypoxic respiratory failure and ARDS secondary to COVID, OSA on CPAP nightly (auto set) follows at FV - PSG in 1989 with AHI 41 events per hour, O2-dependent COPD on nebs/steroids - no signs of exacerbation. Will taper steroids, Mediastinal mass, multiple spinal lesions, right sided pulmonary nodules. Brain MRI with suspected metastatic lesion in the skull, not the brain. Vertebral lesion was biopsied in Oct 2021 - not diagnostic. Followed by oncology Doctor still without a confirmed diagnosis of metastatic disease, although suspected. Pulmonary embolism - Noted on CTA chest 5/1/21 - continue Xarelto. Covid: Positive test and admission 1/21. Symptoms started around 1/18. Methylprednisolone 125 mg IV BID - increased to 60mg q6h on the basis of a slight increase in CRP with ongoing hypoxemia. Reduced to 40mg q8h on 1/28 and will change to Decadron 6 mg/day starting tomorrow (1/31), D-Dimer 3.77 on Xarelto already for HX of PE (May 2021), Treated with several ABX for possible concurrent bacterial pneumonia - stopped 1/24 without current concern for bacterial infection, s/p tocilizumab on 1/24. Ongoing aggressive supportive cares with CPAP. As of 1/28, wants to continue current level of support but no longer favors intubation if needed. Cardiac/Hemodynamics: no active issues. Renal/Fluids/Electrolytes: daily Lasix, Mild hyperkalemia, resolved. ID/Sepsis/Severe Sepsis: Covid - see above, Initial concern for bacterial pneumonia - treated with ABX, stopped 1/24, Urine antigens negative and currently no concern for bacterial infection. Heme: Leukocytosis - infection + inflammation, Normocytic anemia - no sign of active blood loss, Mild thrombocytosis. Neuro: no active issues, generalized weakness with some falls at assisted living. Nutrition: Appears intact at baseline. Taking some PO - monitor. Endocrine: accuchecks and SSI given steroid use and inconsistent PO intake. Sedation/Analgesia: PRNS. Restraints:  Not indicated. Lines/Site: PIV. Disp./Code Status: DNAR/DNI as of 1/28 - when discussing intubation he says, "yeah but if we do that, I'm dead." Discussed the statistics of survival to discharge should our current regimen NOT work and he require intubation - he does NOT want a vent and confirmed that he would choose comfort cares if his clinical situation worsens. Prophylaxis: DVT. Prophylaxis: Xarelto. Glucose control - subcutaneous insulin. Ulcer Prophylaxis: PPI.