Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Atrial fibrillation, Brain natriuretic peptide increased, COVID-19, Chest X-ray normal
Clinical narrative: BRIEF OVERVIEW: Admission Date: 3/5/2025 Discharge Date: Mar 11, 2025 Discharge Disposition:  home or self care   Active Issues Requiring Follow-up:  Follow-up progressive lung cancer recently started on chemotherapy with Oncology; follow up neutropenia with Oncology, they will get repeat CBC with Diff on 3/14, precautions given to family re neutropenic fever with recommendations to call oncology if she has fever, follow-up with pulmonology regarding patient's advanced chronic obstructive pulmonary disease and hypoxia with exertion recovering from COVID-19 infection having completed 5 day course of remdesivir being discharged on Decadron 6 mg daily to complete 10 day course.  Follow up with Cardiology regarding patient's paroxysmal atrial fibrillation with transitioned from carvedilol to diltiazem due to her severe lung disease.  Follow up with Cardiology and primary care history of hypertension with patient normotensive off of her home losartan which was discontinued on discharge. DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hyponatremia [E87.1] Elevated brain natriuretic peptide (BNP) level [R79.89] Chronic obstructive pulmonary disease with (acute) exacerbation [J44.1] Acute hypoxic respiratory failure [J96.01] COVID-19 [U07.1]  70-year-old widowed female with past medical history significant for longstanding nicotine dependence with ongoing tobacco abuse, severe chronic obstructive pulmonary disease (GOLD 3) in the setting of panlobular emphysema, left lower lobe adenocarcinoma/right middle lobe squamous cell carcinoma with progression in the right and left upper lungs recently started on combination chemo/immunotherapy with Taxol, carboplatin and Keytruda presented with worsening shortness a breath found to acute respiratory failure with hypoxia in the setting of respiratory viral panel positive for COVID-19.  Chest x-ray showed no evidence of consolidation.  HOSPITAL COURSE: Patient was started on supplemental oxygen plus IV remdesivir 5 day protocol and dexamethasone 6 mg daily.  She was initially continued on her home beta-blocker and oral apixaban for her paroxysmal atrial fibrillation.  She was noted to have intermittent rapid ventricular rate on her home non cardioselective beta-blocker.  Notably patient has preserved left ventricular ejection fraction on prior echocardiogram.  Patient had intermittently low blood pressures and we held her home angiotensin receptor blocker.  She remained normotensive off of her losartan.  After extensive discussion with pulmonology was decided to transitioned from non cardioselective beta-blocker diltiazem for rate control of her atrial fibrillation.  She did have some intermittent slow ventricular rate during the transitioned but once on diltiazem long-acting 240 mg daily her rate was well-controlled in the 60s.  Discussed informally with Cardiology who is in agreement.  Patient was weaned off supplemental oxygen felt better each day.  She had no evidence of fevers or other focal signs of new infection and was discharged in stable condition.  Walking oxygen desaturation test on day of discharge did show desaturation to 85% with exertion so patient was sent home on 2 L of supplemental oxygen by nasal cannula to be used with exertion and for recovery.  She was noted to be neutropenic.  Discussed with Oncology.  Plan to repeat CBC with Diff on 3/14 and monitor for fevers at home.   On separate note, patient had issues with poor appetite and was started on Megace as an appetite stimulant.  Patient was counseled regarding importance of smoking cessation and felt she was going to make a concerted effort to stop smoking.  She denied any need for nicotine replacement therapy reporting smoking less than 5 cigarettes per day.  And was for patient to stay with her son and daughter-in-law for her 1st week of recovery. Discharged to Home.