Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anticoagulant therapy, Atrial fibrillation, Bronchiectasis, COVID-19
Clinical narrative: Discharge Provider: MD Primary Care Provider: MD Admission Date: 9/23/2022 Discharge Date: Oct 18, 2022  PRESENTING PROBLEM: Acute respiratory failure with hypoxia (HCC) [J96.01] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 72yo M with PMH of follicular lymphoma (on treatment with obinutuzumab), recently diagnosed Afib and drug-pneumonitis during recent admission. He was admitted to the ICU for acute on chronic hypoxic respiratory failure as well as shock. CT chest showed worsening bilateral opacities and new bronchiectasis concerning for infectious vs inflammatory process with developing fibrosis. He was diagnosed with COVID-19 infection which was felt to be responsible for his acute changes. He was started on remdesivir. He was also started on cefepime (7 day course) and azithromycin (5  day course) for empiric bacterial PNA coverage. He takes bactrim and acyclovir prophylacticaly as he is at risk for other opportunistic infections given his immunocompromised status, these were continued. He continued to require high flow nasal canula for hypoxia.    Initially he required pressor support with norepinephrine, but was able to wean off vasopressors on 9/26. Echo was obtained which showed an EF of 57% with no regional wall motion abnormalities and normal RV function. He was given a load of digoxin for atrial fibrillation which controlled his rates well and was also started on heparin gtt. He spontaneously converted back to normal sinus rhythm. He continued to improve and was transferred to general medical service.   After transfer out of the intensive care unit, patient respiratory status did improve.  Was eventually transitioned to nasal cannula at rest.  Pulmonology recommended continue with IV steroids 30 mg Solu-Medrol 2 times a day for 10 days.  He finished day 10 of IV steroids on 10/03.  Also pulmonology recommended he be diuresed to help improve ventilation and further wean his O2.  Recommendation for steroid wean after done with IV steroids was to start 50 mg prednisone 10/3 to wean by 10 mg every week until tapered off.  Patient is on prophylactic Bactrim and acyclovir already as noted above.  He was also transitioned to Eliquis for blood clot prevention given AFib diagnosis.  There was a potential cost issue with him being able to afford Eliquis but patient adamant did not want to be on Coumadin.  So plan will be to discharge with Eliquis and wife has insurance paperwork form she will complete to see if this would allow him to afford the medication and have it paid for by insurance going forward. PT saw pt 10/3 and recommended acute rehab; PMR consulted.    As patient continue to go in a.fib with RVR and required noinrebreather with activity, he was not able to transfer to acute rehab. Cardiology was consulted and they started digoxin. On 10/10/2022, he was started on amidoarone. Patient's hypoxia was very slow to improve delaying discharge. He stabilized to 4L NC at rest, but with minimal exertion like going to the bathroom would desat and require either 10L with oximizer or 15L NRB to help recover and could take a couple mins, but would recover. This was discussed with pulmonology and attributed to significant deconditioning. He was as optimized as possible for rehab, despite the significant oxygen requirements with activity. Given the stability of his oxygenation at rest and consistent recovery with oximizer/NRB with activity, he was transferred to MFB for acute rehab on 10/18/22.