Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Computerised tomogram thorax abnormal, Condition aggravated, Dyspnoea, Dyspnoea exertional, Fatigue
Clinical narrative: HOSPITAL COURSE: Patient is a 73 y.o. male with a past medical history of COPD, HTN, HLD, prediabetes, GERD and BPH who presented to the ED on 01/10/2021 for evaluation of SOB, found to be COVID-19 positive. Has received 2 series Moderna vaccine (9/2021), not yet booster. W/ ~2 weeks worsening SOB, worsened over past ~4 days w/ associated fatigue/congestion/N/V. Requiring 3-4L at rest on presentation. COVID positive. No leukocytosis, Procal negative, unlikely overlying bacterial PNA. CRP 6.9. Trop/BNP negative. D-Dimer WNL 0.48. CXR w/ small focal opacity in LUL (scarring vs atelectasis vs infiltrate vs neoplasm, recommend f/u in 1 month), initially started on ABX but these were d/c'ed given negative Procal. CTPE w/out PE, w/ PNA. Procal negative, do not suspect PNA at this time. Patient was started on Decadron and able to be weaned to his PTA 2L NC O2 regimen. Initially, patient desatted with activity and required 6-7L to maintain his SATS, however, after a few days, he was able to maintain his SpO2 on his baseline 2L O2. Patient requested a urology consult during this hospitalization to manage his BPH as he does not want to drive to outpatient clinic, however, we discussed that this should be handled as an outpatient and patient agreed. He also requested a new PCP set up with local Hospital, our contacts will arrange an appointment for this patient. He was instructed to quarantine through 1/20/22 and understands this. Home health care, PT, OT orders were sent. Patient understands and is in agreement with this plan. PCP Recommendations:- F/U on COVID recovery- Establish care as patient requested new PCP. HOSPITAL COURSE BY PROBLEM: COVID-19 Pneumonia, Vaccinated (no booster). COPD w/ Acute Exacerbation, resolved. Acute on Chronic Hypoxic Respiratory Failure (baseline 2L), resolved. Has received 2 series Moderna vaccine (9/2021), not yet booster. W/ ~2 weeks worsening SOB, worsened over past ~4 days w/ associated fatigue/congestion/N/V. Requiring 3-4L at rest on presentation. COVID positive. No leukocytosis, Procal negative, unlikely overlying bacterial PNA. CRP 6.9. Trop/BNP negative. D-Dimer WNL 0.48. CXR w/ small focal opacity in LUL (scarring vs atelectasis vs infiltrate vs neoplasm, recommend f/u in 1 month), initially started on ABX but these were d/c'ed given negative Procal. CTPE w/out PE, w/ PNA. Procal negative, do not suspect PNA at this time. Patient is not currently candidate for tocilizumab/baricitinib as not requiring high O2 needs. Continue 2L NC O2 with exertion and rest, Continue PTA inhalers, scheduled albuterol (avoid nebs if able given COVID status) home PT/OT/SN. Suspect chronic CO2 retainer. Patient with elevated CO2 on admission. Likely, given COPD diagnosis with baseline 2L NC O2, patient retains CO2 at baseline. Patient is alert and oriented, no encephalopathy. VBG with normal pH. Will continue to monitor. HTN HLD, Continue PTA amlodipine 5 mg daily, rosuvastatin 5 mg qHS, Prediabetes, Last available A1c 6.3 in 2018. On PTA metformin. Was given SSI here. Resume PTA metformin given recent contrast. GERD: Continue PTA PPI. BPH, Continue PTA doxazosin d/w patient importance of outpatient f/u.