Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: Blood glucose increased, Blood magnesium normal, C-reactive protein increased, COVID-19, COVID-19 pneumonia
Clinical narrative: Patient vaccinated 3/10/2021, admitted 8/7/2021, tested positive for covid 8/7/2021, 8/19 and 8/21. discharged 8/22/2021 to home.  admitted with COVID undergoing treatment Date of Clinic Visit or Hospitalization: 8/7/2021  Reason for clinic visit or hospitalization: COVID COVID-19 positive test result: Yes, 8/7/21  Plans to monitor (include medications if prescribed):dexamethasone and remdesivir   History Of Present Illness Patient is a 85 y.o.  Male with a PMH of GERD, BPH, OSA, DMII, CKD, HTN, HLD, CAD with MI s/p PCI (5/2017) who was diagnosed with COVID19 about 5 days ago presents to ED for dyspnea.  Pt is alert and oriented x 3 but a very poor historian.  Pt reports he was exposed to COVID19 by another family member a few weeks ago.  His wife was admitted here with COVID19 about 3 days ago.  Pt began having dyspnea on Monday (8/2) which has become progressively worse.  Pt reports dyspnea is worse on exertion and causes anxiety and panic with chest tightness when it occurs.  Pt reports fever and chills over the last few days.  Pt reports nausea and diarrhea but states, "very little"  Pt denies vomiting, abdominal pain, dysuria, cough, congestion, sore throat, heart palpitations, or travel.  Pt with recorded SpO2 as low as 92% on room air on presentation with tachypnea 20-30's.  Pt reportedly was hypoxic at home with SpO2 in the high 80's per family who is no longer at bedside.  Pt on 3L nasal cannular on admission with SpO2 97%.  Pt with temp 100.2.  Labs significant for WBC 10.57, CRP 152, troponin 33, glucose 377, sCr 1.7, magnesium 1.4, and ical 4.4.  ECG normal sinus without acute ST changes.  CXR shows cardiomegaly, aortic vascular calcifications, low lung volumes, and patchy left greater than right airspace opacities consistent with atypical or viral infection, including COVID19.  CT PE shows no pulmonary embolism but bilateral ground glass airspace disease consistent with viral pneumonia.  IM consulted for admission.   Review of Systems  Constitutional: Positive for chills and fever. Negative for fatigue and unexpected weight change.  HENT: Negative for congestion, hearing loss, postnasal drip, rhinorrhea, sinus pain, sore throat and trouble swallowing.   Respiratory: Positive for chest tightness and shortness of breath. Negative for apnea, cough, wheezing and stridor.   Cardiovascular: Positive for chest pain. Negative for palpitations and leg swelling.  Gastrointestinal: Positive for diarrhea. Negative for abdominal distention, abdominal pain, constipation, nausea and vomiting.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Rhonchi present. No wheezing.     Comments: Rhonchi in the LUL and diminished throughout  Hospitalization Admit Date/Time: 8/7/2021  6:20 PM Admitting Attending: Doctor M. Discharge Date: 08/22/21 Discharge Attending Physician: Doctor G.  PCP name and Address:  No Pcp None Referring provider name and address:  No referring provider defined for this encounter.   Chief Concern, Brief History of Present Illness, and Hospital Course 85 y.o. Male with a PMH of GERD, BPH, OSA, DMII, CKD, HTN, HLD, CAD with MI s/p PCI (5/2017) who was diagnosed with COVID19 about 5 days prior to admission Is admitted with acute respiratory failure with hypoxia secondary to Covid 19 viral pneumonia.  Per patient he was vaccinated with Johnson & Johnson vaccine in May and pharmacy is attempting to contact family to get the vaccination card to officially document breakthrough case. The patient is currently on 3-4 L of nasal cannula and appears to be progressing well.  He is on Remdesivir and dexamethasone.  Patient has hyperglycemia likely secondary to steroid use in the setting of uncontrolled type 2 diabetes.  His last hemoglobin A1c was 9%. He is currently on Lantus of 30 and lispro 10 units 3 times a day with meals.  Adjusted insulin per FSBG.   85yo Male PMHx OSA, DMII, HTN, CAD with MI s/p PCI (5/2017) who was diagnosed with COVID19, presents with worsening dyspnea.   #) Viral pneumonia secondary to SARS/CoVID-19 pneumonia #) Acute hypoxic respiratory failure requiring supplemental oxygen secondary to COVID 19 Pt began having dyspnea on 8/2 which has become progressively worse.  He completed Remdesivir 200mg on day 1, then 100mg daily for 4 days (start 8/8) CRP 46.9->29.8->17.1->11.7->8.2->5.5 /Plan: - Dexamethasone 6mg PO daily x10days (started 8/10, RECOVERY Trial protocol) -  Oxygen per nasal canula. Titrate O2 for 92-96%, on RA now. - Airborne precautions, including use of N95 masks, face-shields, gown, gloves - Albuterol HFA inhaler Q4h PRN - Acetaminophen 650mg PO Q6h PRN for fever - Pantoprazole while on steroids   #) Diabetes Type 2, Uncontrolled, with Hyperglycemia A1c = 9.1 (8/7), Glucose was 377 on admission Pt on Glipizide and Lantus 24 units at bedtime His Glc inpatient has been labile, ranging between 80's and 300's. This is worsened by the steroids /Plan: Insulin lantus and lispro during hospital stay with ISS.  -   Lantus 30U at bedtime at home,  decreased here, recc to continue as 15 units on discharge.     #) Chronic Kidney Disease, Stage 3b sCr 1.7->1.48->1.72->1.58->1.45->1.43->1.39->(resume ACE)->1.37->1.44 Baseline unknown, but this may be his baseline. Cr is varying less than 0.3 and he has diabetes. Plan: - Continue tamsulosin - Resume home Enalapril (resumed 8/14, expect 30% Cr rise due to hemodynamics not injury) - d/c home Furosemide     #) Coronary Artery Disease s/p PCI (5/2017) /Plan: - Continue home Metoprolol 12.5 BID - Continue home ASA, statin -  home Enalapril   #) Hypertension - Continue home Metoprolol 12.5 BID - Resume home Furosemide 20mg as needed after f/u with PCP. - home Enalapril   #) OSA Patient and his son both say he uses a "mask" all night while sleeping, and provides humidified air - CPAP at night (start with 5cm pressure)   #) Hyperkalemia K=4.9->4.5->5.8(hemolyzed)->4.3->4.1->4.2 - Resume home Furosemide 20 - Low K diet - Increase insulin as per Diabetes   #) Thrombocytopenia - likely secondary to Covid. Monitor #) Hypomagnesemia - Monitor and replace #) Hypocalcemia - Monitor and replace #) Benign Prostatic Hyperplasia - Resume home Tamsulosin #) GERD - Resume home PPI    #) Fluids/Nutrition - Low K consistent 2carb diet   #) Prophylaxis - Enoxaparin 30mg subcu BID   #) Discharge Planning  wean off O2. Pt on RA Talked to pts son, after talking to IPAC, pt can be discharged home. Pt can stay with his wife.