Age: 78.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Nutritional supplementation, Oesophagitis ulcerative, Oesophagogastroduodenoscopy abnormal, Pneumonia, Procalcitonin
Clinical narrative: Discharge Provider: MD Primary Care Provider: DO Admission Date: 2/18/2023 Discharge Date: Feb 24, 2023  PRESENTING PROBLEM: Community acquired bilateral lower lobe pneumonia   HOSPITAL COURSE: Patient is a 78 y.o. female with a past medical history of Billroth 1 surgery for PUD in the past who presented with shortness of breath, hypoxia, nausea, vomiting, poor oral intake.   Patient came as a direct admit from inpatient. She was admitted there on 02/19/2023 with nausea, vomiting, abdominal pain, foubd to be positive for COVID-19 infection.  Over the next few days she started developing cough, shortness of breath, hypoxia and had to be put on supplemental oxygen which not taking at home for chronic obstructive pulmonary disease although she is on chronic prednisone.  Due to the nausea and 1 she has had very poor po intake.  GI and General surgery had been consulted given her previous history and upper GI series showed small hiatal hernia but otherwise unremarkable except for postsurgical anatomy.  She transferred here for further care including artificial nutrition. Chest x-ray and CT thorax showed bilateral ground-glass opacities consistent with likely COVID-19 pneumonia, scattered mucous plugging and there was also noted on aortic arch plaque at high risk for embolization.  She was also found to have of procalcitonin of 18.5 and was started on Rocephin and doxycycline and completed course and was weaned to room air.   GI was consulted and took her for EGD on 2/18 showing ulcerative esophagitis and erosive gastritis biopsies were negative for H pylori.  Negative for fungal organisms.  She continued on ppi and carafate.  She had GI place corepak on 2/20 since oral intake remainted poor.  Unfortunately patient continued to have intractable nausea with dry heaving.  Did tolerate the jejunal tube feeds.  Reviewing past medical history patient had very similar episodes of intractable nausea and vomiting in the past including 2021 during which she saw Gastroenterology and had a thorough workup performed.  Essentially the thought was she may have some hypomotility related to her previous Billroth surgery but no other definitive cause was found.  In-hospital patient was continued on p.r.n. Zofran Compazine and Tigan.  GI reconsulted but did not have significant additional recommendations.     Additional issue brought to light during this hospitalization is patient has chronic prednisone use.  Patient was started on prednisone for nausea in 2021. No labs are available previous to the start of prednisone in epic.  Cortisols levels in system were drawn after patient was already on steroids.  No clear previous diagnosis of adrenal insufficiency.  Patient gave history of PCP adjusting prednisone dosing up and down based on her nausea symptoms.  On admission patient had been placed on increased prednisone dose 40 mg daily for chronic obstructive pulmonary disease component with pneumonia.  This did not improve her nausea or vomiting.  Also trialed IV dose of Decadron with no improvement.  Patient did not have hypotension.  Blood sugars stable.  Endocrinology consulted but declined consult.  Did place recommendations in chart.    Recommendations: "In the interest of safety given her long term use of steroids would: - continue steroids and wean to no less than 5mg of prednisone OR  10mg in am and 5mg in afternoon of hydrocortisone. -needs instructions to double dose for 3-5 days during times of acute illness.   -Will also need to always wear a medical alert for adrenal insufficiency -provide Rx at discharge for injection steroids for times when unable to take oral steroids for >24h.   If wean is desired still would: -check 21 hydroxylase antibodies for addisons disease, if positive, then pt will never be allowed to wean off. -wean down to 5mg prednisone daily and then drop by 1mg every 3-4 weeks until off then have 8am cortisol/ACTH testing.  If acute illness develops then still needs to stress dose for 3 days before dropping back to prior dose."  Patient decreased back to baseline prednisone dosing and then on discharge transitioned to hydrocortisone after discussion with pharmacy regarding dosing 30 mg in a.m. 20 mg afternoon.  Have given instructions to care facility regarding possible future need for stress dosing and emergency injectable hydrocortisone if unable to take po.  Discussed with patient and with son and recommended outpatient endocrinology consult for further management.  Twenty-one hydroxylase pending at time of discharge.   Finally despite continued nausea discussed with patient and son as no further workup recommended in-hospital patient stable on Corpak to jejunal feeds will discharge to rehab with p.r.n. Zofran and Compazine as well as PT OT.  Patient to return to ER if symptoms worsen or new issues arise.