Age: 77.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: White blood cell count increased
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD  Admission Date: 9/17/2022 Discharge Date: 10/12/22   PRESENTING PROBLEM: Acute on chronic respiratory failure with hypoxia and hypercapnia (HCC) [J96.21, J96.22] Respiratory failure (HCC) [J96.90]   HOSPITAL COURSE:    77-year-old male with past medical history chronic obstructive pulmonary disease on 2 L, enlarging lung nodule, chronic Foley secondary to BPH, stage IV decubitus ulcers, diastolic heart failure, and chronic ulcer of the left midfoot who was admitted to the ICU on 9/17 for respiratory failure.   Pt presented to ER for acute stroke-like symptoms.  Patient's last known well was last night per EMS.  Family notice slurred speech and left-sided facial droop.  By the time he presented to the ER he was more responsive but had rhonchorous breath sounds, cough and was on 4 L nasal cannula which is above his home oxygen level.  Oxygen requirements progressively increased to 6 L. Facial droop and slurred speech persisted which according to family is not baseline.  Patient ultimately was intubated and sedated due to worsening hypercapnia/hypoxia and mentation. Labs noted leukocytosis w/ WBC 17.8 and hyponatremia of 128 which improved after 1L IV fluids. CT Chest revealed a LLL pneumonia. UA was also positive w/ hematuria and pyuria. Pt was started on Vanc/Zosyn and was transferred to ICU.    In the ICU, pt required Norepi and was started on Methylprednisone and duonebs. He was transitioned from Vanc/zosyn to Merrem due to a hx of multidrug resistant UTI's. Repeat UA after foley change remained positive. However, Urine cultures grew mixed floras. Pt underwent a workup for his AMS/CVA-like sx's which included CT, CTA, MRI, and MRA of the head. These were nonpathologic. Neuro concluded his initial presenting sx's were secondary to toxic metabolic encephalopathy. Pressors were weaned off on 9/19. On 9/20, after becoming arousable and following commands, he was extubated. Post extubation pt was alert and neurologically intact.  Has been requiring high-flow nasal cannula which we have been weaning.  Blood cultures continue to show no growth. He does have a stage IV decubitus ulcer which has been noncontributory to his current condition. He remains off of pressors, A/Ox4, and is stable for transfer now that he is down to FiO2 of 50% on high-flow.   Patient noted to have a history of a RUL lung nodule which was noted to be enlarging from 11/2021 to 6/8/22. PET (8/16/2022) showed right upper lobe pulmonary nodule that was hypermetabolic and considered suspicious for primary bronchogenic carcinoma, equivocal nonenlarged mildly hypermetabolic precarinal and right hilar lymph nodes and no evidence for distant metastatic disease. Pt was scheduled for a CT-guided bx w/ U. Patient understands concern for malignancy but unable to give diagnosis an until biopsy preformed.     Patient was in Covid isolation per SAR requirements and developed CAUTI and HAP vs Aspiration pneumonia. Patient was evaluated by pulomonary, infectious disease, SLP, PT/OT and was on broad spectrum antibiotics which were deescalated to augmentin upon discharge.  Patient was discharged in good condition to SAR.