Age: 56.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Unintentional medical device removal
Clinical narrative: Hospitalized 01/15/2022-still currently admitted; COVID-19 positive 01/18/2022; fully vaccinated plus booster  COVID 19 infection Acute hypoxemic respiratory failure -Symptom onset 1/2/22  -Vaccination status: vaccinated with pfizer  -Currently requiring 4 L O2 (came into ED on room air, began requiring oxygen around midnight) -CXR 1/14 independently reviewed, with bilateral patchy opacities and pulmonary vascular prominence -Repeat CXR ordered 1/15 as patient is now requiring oxygen. Unclear if this is related to fluid bolus or worsening covid 19 pneumonia -Start Decadron 6mg daily x 10 days (start 1/15) -Monitor daily covid immunology labs -VTE prophylaxis with subcutaneous heparin -IS q 1hr while awake, prone positioning prn   Acute respiratory failure with hypoxia (HCC) Overview -Admitted on 01/15/2022 with COVID pneumonia, required 4 L nasal cannula -Escalated to 80% high-flow nasal cannula by 1/16 -By 1/17 requiring 95% FiO2 via high-flow nasal cannula, P/F ratio 79 on blood gas, saturations in the low 90s at rest.  Nursing concern is desaturations whenever he gets out of bed, often does not hit the call light and pulls off oxygen supply with significant desaturations that take numerous minutes to recover with high-flow and non-rebreather. - Intubated 1/18/22 01/25/2022 notes: Acute respiratory failure with hypoxia (HCC) Assessment & Plan Secondary to COVID pneumonia/ARDS and superimposed bacterial pneumonia. Intubated 1/18. Chest imaging w/ bilateral patchy opacities.  - Continue lung protective ventilation, daily SBT/SAT, weaning sedation for vent synchrony, no longer requiring paralysis and proning, VAP ppx.  - I/O goal even, lasix had been held per renal for hypernatremia, and will reach back out to nephrology about fluid goals - Completed empiric zosyn x 5 days on 1/21, all cultures negative - Continue therapeutic anticoagulation for multiple RUE thrombi - COVID-specific therapy below   Pneumonia due to COVID-19 virus Assessment & Plan Vaccinated, immunosuppressed. Symptom onset: 1/2/22. Test positive: 1/6/22. Admission: 1/15/22. Intubation: 1/18/22.  Remdesivir: outside window Steroids: Dexamethasone 6mg daily (1/15-1/17), solumedrol 40mg IV BD (1/17-present), decrease to 30mg IV BID solumedrol 1/26 Plan for 1/27: Will re-culture given persistent fevers this AM Start empiric Vanc/Zosyn; obtain MRSA PCR Continue to wean IV sedation as able; start Seroquel to assist with this. May need precedex.   Repeat cultures for fever overnight, procal is elevated,question slightly worse, will restart zosyn and vancomycin with de-escalation based on culture data, if no growth on sputum, will consider bronchoscopy given chronic immunosuppression. Had already completed course of cefazolin for suspected superimposed bacterial pneumonia earlier in course. Continue ventilator support, agitated, using oxycodone and klonapin for sedation weaned off, and will add seroquel for agitation before adding precedex. Steroid wean for COVID-specific therapy, on 30mg solumedrol BID, decreasing every 3d. Lasix for goal negative fluid balance. Tacro per nephrology for renal transplant. Heaprin gtt for RUE DVT.    01/31/2022 notes: Persistently febrile: blood cultures sent again Sputum culture still positive for pseudomonas, continue Zosyn for 7-10 course. Send for CT chest, new right sided pneumothorax, stable on interval chest xray today but with fevers need to exclude a parapneumonic process.