Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: X-ray limb normal
Clinical narrative: vaccinated for COVID-19 including booster dose who presented to the emergency department because of confusion, hypoxia, syncopal episode.  Patient is not very clear on the details.  At the time of my interview, his confusion was a little bit better but he was actually quite sleepy. Patient was found unconscious in the bathroom by his wife.  It was unknown how long he was unconscious but there was no obvious head trauma.  Over the past several days patient has had decreased p.o. intake, increasing confusion.  He said his symptoms started around 12/25/2021.  He tested positive on a home test on 1/1/2022.  His wife and he have been monitoring his oxygen saturations and they were more than 90% all this time until the day of admission when he was 70% on room air.  Wife called 911.  From the fall, he did sustain a laceration to his right elbow.  Patient complains of being short of breath, having a cough, some fevers and chills.   In the ECC, patient was afebrile, mildly tachycardic, tachypneic.  He was initiated on OptiFlow by the respiratory therapist.  Labs showed white count of 3.2, potassium 3.3, sodium 135, AST 65.  Chest x-ray showed airspace opacities in both mid and lower lungs compatible with pneumonia.  There is also an indwelling Port-A-Cath.  Right elbow x-ray did not show any evidence of fracture or subluxation.  CT scan of the head was also normal.  PROGRESS NOTE 1/16/2021 ASSESSMENT/PLAN 74 year old male with a history of hypertension, diffuse large B-cell lymphoma who completed 6 cycles of R-Chop therapy from 6/16 - 9/26 who came to the ER for increasing shortness of breath and some confusion.  He was diagnosed with covid-19.  His procal is noted to be negative at 0.11 so he has not been on antibiotics.  He does continue to require significant amount of respiratory support.   1) Acute Hypoxic Respiratory Failure -   Secondary to covid-19 pneumonia   - initially had symptoms on 12/24 - confirmed to be positive on 1/5, fully vaccinated and boostered  - continue full barrier  - Persistent high O2 needs since admission, O2 LPM: 40 LPM, O2 Delivery Source: Opti-Flow 60% FiO2  - nebs  - encourage IS.  Patient was not able to prone as sleeping on his stomach causes him to have increased reflux symptoms.  - procal is 0.11 so no antibiotics are indicated  - not a candidate for tocilizumab or baricitinib due to duration of symtoms  - CRP has been steadily climbing.  Change IV Solu-Medrol to 60 mg every 8 hours.  - Initially patient had kidney injury and hence patient was not given Lasix.  Could consider adding Lasix to advantage the lungs.   2) hypertension- PTA losartan/hydrochlorothiazide is on hold due to acute kidney injury.  Blood pressure has remained stable without any antihypertensives   3) hx of Large B-cell lymphoma - completed R-CHOP therapy 6 cycles - being followed as an outpatient - considering adjunct radiation therapy - On Bactrim and acyclovir prophylactically   4) AKI - resolved.  Creatinine is now at baseline.  - avoid nephrotoxins    5) acute metabolic encephalopathy likely due to COVID-19 and may be even hypoxia from COVID-19- appears to be resolving  - continue the above treatments   7) Hypokalemia - resolved   Malnutrition : Severe Malnutrition   Energy Intake: Less than or equal to 50% of estimated energy requirement for 5 days or greater Interpretation of Weight Loss: Greater than 7.5% in 3 months (19 lbs (8.8%) in under 3 months)   Right elbow laceration -This is from a syncopal episode when he was at home prior to admission Healing well   Prophylaxis - Lovenox 1 mg/kg twice daily for D-dimer greater than 1, omeprazole