Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anion gap, Anticoagulant therapy, Atypical pneumonia, Blood bicarbonate normal
Clinical narrative: Chief Complaint   Patient has been having nausea and vomiting for the last 5 days. Has not eaten in three days. "started running a temp saturday night". No tylenol or ibuprofen today. Exposed to covid 2 weeks ago, tested neg on a rapid.  History of Present Illness     Patient is a 69 year old female with pmh DM2, HTN, depression, hypothyroidism, sleep apnea and asthma presenting to the ED today with complaints of fevers, nausea and diarrhea. In the ED patient was saturating at 87% on room air, improved to 95% with 2L NC. Found to be covid positive, although patient is vaccinated. She received 1L bolus of NS and reglan for nausea. Labwork revealing elevated D-dimer, and glucose of 445 with anion gap w/o acidosis. She received 10U insulin in ED with improvement of glucose to 391, received an additional 5U insulin. Beta hydroxybutyrate   Upon interview, patient reports that 5 days ago she started to feel bad. Describes have fatigue, myalgias, fevers, nausea and diarrhea. Denies any emesis. Has has poor oral intake due to the nausea and has subsequently missed taking some of her home medications. Has been feeling short of breath which has been worsening over the past day or so which promoted her presentation to the hospital today. Notes that she is vaccinated against covid, but was exposed by her daughter who is also admitted with covid currently. Denies any chest pain, headache, sore throat or leg pain.  Review of Systems     All systems reviewed, and is negative except as noted in the HPI.  Physical Exam  Vitals & Measurements  T: 36.5 °C  HR: 72  RR: 18  BP: 151/71  SpO2: 94%  WT: 108.7 kg      General: NAD Head: Normocephalic, Atraumatic Eyes: EOM intact, sclera clear Mouth: mucous membranes moist Respiratory: Diminished breath sounds in the bases, mild coarse breath sounds upper lobes, unlabored, symmetric chest rise Cardiovascular: RRR, no murmurs,  normal S1/S2, +2/4 peripheral pulses bilaterally. Trace pitting edema bilateral LE Abdomen: soft, nontender, nondistended MSK: no gross deformities Neuro: alert and oriented, CN intact grossly, no focal neurologic deficits grossly Psych: normal affect and mood, cooperative  Assessment/Plan      Pt is a 69 year old F pmh HTN, DM2, asthma, depression admitted for acute hypoxic respiratory failure in setting of covid-19 pneumonia. Pt is vaccinated against covi-19, +recent exposure. Requiring 2L NC in ED, will draw inflammatory markers and start Remdesivir and Dexamethasone while titrating oxygen to maintain spO2 > 92%. Also noted to have elevated glucose at 445 as pt missed medications at home, AG of 23 without acidosis. Glucose improved to 381 in ED after 10U insulin, given an additional 5U. Pt's BHB returned elevated at 2.9, suspect in early DKA - will send to PCU for close monitoring/ possible need for insulin drip if glucose fails to downtrend.  COVID-19 Pneumonia:  - symptom onset: 10/2; Date positive 10/7  - CXR showing findings consistent with multifocal atypical/viral pneumonia.  - elevated d-dimer 0.58  - doppler US b/l ordered  - Inflammatory markers ordered and pending  - Start Dexamethasone 6mg daily x10 days (10/7-10/17)  - Start Remdesivir x 5 days (10/7-10/12)  - Continue home inhalers - Albuterol, Advair and Incruse  - requiring 2L NC, titrate as needed to maintain saturations > 92%  Diabetes Mellitus type 2  - home regimen metformin +  insulin 70/30 50-55U BID  - Glucose elevated on arrival 445, received 10U insulin ED with improvement to 381  - AG of 23, not acidotic on VBG - pH 7.33, HCO3 21.9  - BHB elevated 2.92  - Start Insulin Drip and DKA protocol  - Hgb A1c ordered  Asthma:  - continue home inhalers: albuterol, Advair and Incruse  HTN:  - continue home amlodipine 10mg daily  - continue home losartan 100mg daily  Hypothyroidism  - continue home levothyroxine  Depression  - continue home escitalopram, buspirone and amitriptyline  - also takes minalciprin (Savella) at home, although not on formulary here so not continued   Other chronic medical conditions:  Muscle spasms - continue home tizanidine  Code Status: Full Code Diet: Diabetic DVT ppx: Lovenox Disposition: PCU - likely downgrade in the morning if glucose controlled   Patient staffed with attending physician Doctor.