Age: 59.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Sputum culture positive
Clinical narrative: Hospitalized (9.2.21 - still admitted);  COVID-19 positive (8.30.21;  9.3.21);  fully vaccinated  HISTORY OF PRESENT ILLNESS: Patient is a 59 y.o. male who presents today with 7 day history of fever, muscle aches, dyspnea, diarrhea, productive cough and body aches. Patient has a history of RA and is currently on Humira, Plaquenil and Sulfasalazine. He follows with rheumatology.  Patient states he has been full vaccinated with Pfizer COVID-19 vaccination (completed in March) and denies any tobacco use. He states he possible contracted virus possible at a wedding and his wife also is currently being admitted for COVID-19. He tested positive on 8/30 but due to progressive symptoms presented to the ED today.  ASSESSMENT / PLAN: # Acute Hypoxic Respiratory Failure Secondary to COVID-19 PNA -symptom onset 8/27 and tested positive on 8/30 per patient (unable to locate in EMR)  -fully vaccinated with Pfizer vaccination (completed in March 2021) & CXR personally reviewed               -continuous pulse oximetry and target oxygen saturation >90%               -decadron 6 mg daily x 10 days, Remdesivir and monitor LFT's and renal function              -check CRP and if >75 and not improving with decadron consider Tocilizumab              -maintain net negative fluid balance (fluid restriction, 20 mg PO lasix daily) -given immunocompromised state high risk for secondary bacterial PNA              -check pro-calcitonin and will cover with IV Rocephin (1 gm daily) for now              -if pro-calcitonin negative and improving consider discontinuation of antibiotics Aspergillus fumigatus Assessment & Plan Presented with respiratory failure secondary to COVID pneumonia.  Course complicated with increasing oxygenation requirement as result was subsequently brought to the intensive care unit and intubated on 09/11.  Remains afebrile since completion of antibiotic therapy for 5 days empirically with Rocephin/azithromycin on 09/07.  Furthermore, sputum cultures obtained on 09/11-aspergillus fumigatus and 0 9/12-identified isolated fungal species with Candida.  He is a high risk for fungal pneumonia in the setting of COVID -19 along with this history of immune suppression with TNF alpha inhibitor/humeral for his rheumatoid arthritis and CT evidence of subpleural nodules in bilateral lung fields, left greater than right are all reasonable indications in the clinical setting to initiate antifungal therapy. Monotherapy with IV Voriconazole loaded with 6 mg/kg IV BID on 09/14.  Plan: -Will Follow: Fungitell, Aspergillus serum antigen, Repeat Sputum Cx with Aspergillus PCR -Continue Voriconazole 4mg/kg BID for atleast 7 days. Stop dates placed.  Will transition to orally when able. Anticipate total duration of therapy 6-12 weeks, will reassess the need of chronic prophylaxis oral therapy. -Will check through levels 4-7 days into the therapy with goals serum concentration 1-5.5 mcg/ml. And trough level 1-1.5 mcg/kg. Trough level check ordered for 09/17 am.. -Daily CMP to monitor for hepatotoxicity and nephrotoxicity -Agree with holding DMARDs  * Pneumonia due to COVID-19 virus Assessment & Plan Vaccinated fully with Pfizer vaccine in March 2021 (immune compromised); Sx onset 08/27, tested positive 8/30 admitted on 09/02.  Has finished appropriate 5 day therapy with remdesivir, dexamethasone from 09/02-09/11 x 9 days. CAP coverage completed w/ Rocephin/Azithromycin 09/02-09/07