Age: 66.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Hypernatraemia, Hyperosmolar state, Hypovolaemia, Hypoxia, Infectious pleural effusion
Clinical narrative: 11/13/2021 - arrives to ER from nursing home with complaints of altered mental status and hypoxia, with known diagnosis of covid pneumonia on 11/8/2021. Received monoclonal antibodies on 11/9/2021- apparently tolerable acute respiratory failure- received 2L O2 at nursing home. In ED patient found to have sepsis- 101 temp, HR 101, O2 sat 88% -placed on 100% BIPAP. Tested covid positive on admit. Chest Xray showed severe COPD with possible right base infiltrate. CRP 17.3, Started on 15L O2, continued BIPAP, high-dose steroids, doxycycline,cefaxitrone, IVF NS. H/O kidney disease  with acute kidney injury, crt 4.5, BUN 72, NA145, HCO3 19 remdesvir held, started baricitinib 2mg daily. Unable to give DVT prophylaxis  due to black tarry stool. Pt 15.5, INR 1.32 -holding heparin to r/o GI bleed 11/15 - CRT 5.3, EGFR <12- anion gap 14,metabolic acidosis, hypovolemic hyperosmolar hypernatremia with hyperchloremia - switch NS to .45% saline, oral bicarb 650mg tid. Antiembolism stockings applied for DVT prophylaxis, antibiotics and steroid continued 11/16 - Heparin started for DVT prophylaxis 11/19 - hypernatremia resolved- .45% saline d/c, Cr improving 4.5/5.7/5.3/3.8/3.4/2.8/2.4 - d/c IV hydration, continuing bicarb - anion gap 7 11/26- severe resp distress - chest xray revealed worsening of bilateral pneumonia/newly imposed hospital acquired. Cefepime IV, Flagyl, 30L HF O2 - increased O2 demand. Last covid swab 11/24 was positive. WBC 19. AKI back to baseline - Lasix initiated 11/27- d/c baricitinib. Hold Lasix - worsening renal function. Cr 2.8, BUN 45 12/4 - Covid vs HA pneomonia improving - weaned to 8L O2. Antibiotics continued. AKI stable. Heparin continued for DVT prophylaxis. 12/5/2021 - repeat covid swab negative 12/6/2021 - WBC count elevated 32.8 from 21.2, ANC 29.8 from 18.4, CRP trending down to 1.9 from 3.2. Chest xray shows left perihilar consolidative infiltrates similar, multilobar pulmonary infiltrates, and cardiomegaly, similar to prior exam. Repeat CT chest shows severe pneumonia left upper lobe with small parapneumonic effusion. O2 requirements 1-2L. Try to wean off. Heparin continued. 12/8 - WBC 36.3. Persistent leukocytosis/pneumonia -Current antibiotics held. Started on Meropenem and Linezolid. Continue Prednisone with taper, Doxy d/c. On room air, SpO2 greater than 9 12/9- H&H 7.5, 22.4 - down from 8.4, 25.4 on 12/8 - 1 unit RBC given 12/10- Bronchoscopy performed. Bronchoalveolar lavage grew E.Faecium, VRE +ve. Leukocytosis trending down to 27.6<--29.2 wbc. Meropenem and linezolid, prednisone continued.  12/13 - switched Meropenem to Ceftriaxone. Bumex initiated for signs of overload - course ronchusm/b/l upper extremity edema.  12/14 - Aspergillus Fumigatus just positive positive - Voriconazole added - 6 month regimen. 12/16 - H&H 6.9, 21.6 - 2 Units RBC given. - Hemoglobin stable at 8.6 following transfusion 12/22 1 unit transfused RBC - H&H 7.3, 21.8 12/24 - WBC normal 10.0, Hemoglobin 8.2 12/25 Hemoglobin 8.4 continued improvement. 12/27 - Completed 14 days IV Zyvox, last dose of ceftriaxone. Will continue Voriconazole. Preparing for discharge.  12/28 - Discharged