Age: 75.0
Sex: F
Vaccine: COVID19-2
Symptoms: General physical health deterioration, Gram stain positive, Intensive care, Lactic acidosis, Legionella test
Clinical narrative: COVID+ 1/13/2023.  Vaccination Status moderna x3 + Moderna BIVALENT -x1 Initial hospitalization at hospital 12/15/22-12/18/22 followed by transfer different hospital 12/18/22=1/13/23 BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider at Discharge: MD  Admission Date: 12/15/2022 Discharge Date: 12/18/2022   Active Hospital Problems   Diagnosis Date Noted POA ? Acute respiratory failure with hypoxia  12/16/2022 Yes ? Severe sepsis  12/16/2022 Yes ? Pneumonia due to COVID-19 virus 12/15/2022 Yes ? Pneumonia due to infectious organism 12/16/2022 Yes ? Staphylococcus aureus bacteremia 12/16/2022 Yes ? Rheumatoid arthritis  08/14/2015 Yes ? Essential hypertension 02/19/2016 Yes ? Stage 3b chronic kidney disease  10/15/2020 Yes ? Type 2 diabetes mellitus with stage 3b chronic kidney disease, without long-term current use of insulin 02/19/2016 Yes ? Tophaceous gout   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Severe sepsis  [A41.9, R65.20] Pneumonia of both lungs due to infectious organism, unspecified part of lung [J18.9] Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1] HOSPITAL COURSE:  75-year-old female admitted for hypoxic respiratory failure, sepsis, COVID.  She did to home test approximately 6-7 days ago was found to have COVID positive.  She presented to the emergency room 12/14/2022 and was given dexamethasone.  Her breathing continued to worsen and she presented again 12/15/2022.  Since she had a normal chest x-ray 12/14/2022 a CT scan was performed and revealed bilateral pneumonia.  She had an elevated lactic acid which has gradually gone down.  She was febrile and had a leukocytosis of 13.71.  12/16/2022:  Patient had 2/2 set of blood cultures positive for Gram-positive cocci in clusters.  She is on high-flow oxygen based on demand.  She had continued lactic acidosis.  She is empirically started on vancomycin per pharmacy and had MRSA PCR screening.  If this is negative and blood culture remains contaminant or pansensitive will DC vancomycin.  Sputum cultures, strep pneumoniae antigen, Legionella antigens were all sent. 12/17/2022: Still on Hiflo oxygen. Added BiPAP PRN for risk of respiratory failure and fatigue. Blood cultures positive for S aureus. Started on vancomycin yesterday. ID consult placed yesterday. 2D echocardiogram, fairly normal and shows no vegetations. Has bilateral knee replacements.  Sputum has since also grown Staph aureus.  Will continue vancomycin until sensitivities return.  Then we will deescalate antibiotics.  MRSA screening has been negative. 12/18/2022: Still on Hiflo oxygen. Blood cultures from 12/15 (+) for MSSA x2. Repeat blood cultures (+) from 12/17 x 2. Discussing with ID. Stopped vancomycin, start cefazolin 2 gm Q 8 hours (not nafcillin due to fluid load). Completed TTE 12/16/2022. Back pain improved, but may need to consider MRI if not resolved. ID recommends transfer for TEE. Attestation signed by MD at 1/13/2023  4:19 PM (Updated)   I have personally interviewed and examined the patient on 1/13/2023. Management was discussed with PA. I agree with the documented findings and plan of care in his/her note.   Brief exam:    General: NAD, Awake, alert. Deconditioned.   CVS: RRR Pulmonary: CTAB Abdominal: soft/NT/ND Neuro/psych: no gross neuro deficits, oriented x3   Brief history and medical decision making:    To continue with IV antibiotic for MSSA bacteremia, AV endocarditis.  Six week duration of antibiotics with repeat echo after finished treatment.  Acute kidney injury improving.  Follow-up with pulmonology as outpatient for sleep study, to continue with BiPAP q.h.s. at rehab for now.  Medically ready for DC to rehab on 1/13.  Tunneled CVL placed prior to admission to continue with IV antibiotics after discharge.  Had COVID positive test day of discharge, this was felt to be residual positive as patient asymptomatic and and had recent positive COVID test mid December.   MD Medicine Hospitalist    25 minutes were spent on the unit/floor with the patient with over 50% spent counseling and coordination of care related to exam of patient, discussion care with medicine PA, bedside RN.     BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 12/18/2022 Discharge Date: Jan 13, 2023    Active Hospital Problems   Diagnosis Date Noted POA ? Mucus plugging of bronchi 01/06/2023 Unknown ? Pleural effusion, bilateral 01/06/2023 Unknown ? History of bilateral knee replacement 12/20/2022 Unknown ? MSSA bacteremia with native AVIE 12/19/2022 Unknown ? Post viral pneumonia due to MSSA 12/16/2022 Yes ? Pneumonia due to COVID-19 virus 12/15/2022 Yes ? Stage 3b chronic kidney disease  10/15/2020 Yes ? Type 2 diabetes mellitus with stage 3b chronic kidney disease, without long-term current use of insulin 02/19/2016 Yes ? Rheumatoid arthritis    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: MSSA bacteremia [R78.81, B95.61] Acute respiratory failure with hypoxia [J96.01] Acute hypoxemic respiratory failure [J96.01] Endocarditis [I38]   HOSPITAL COURSE: 75 y/o female transferred from hospital so a TEE could be done to complete MSSA bacteremia work-up. patient was admitted there 12/16 for shortness of breath and cough 2/2 COVID and CAP PNA. two sets of blood cultures were positive for MSSA and she was started on vancomycin with a negative TTE that could not rule-out vegetations. ID was consulted who recommended switching to cefazolin and that she be transferred for TEE. Bcx positive for 12/17 and 12/18 as well. patient also had an AKI. patient decompensated on 12/21 requiring BiPAP and was moved to the ICU. there for three days she was managed for secretions, including bronchoscopy, back to medicine 12/24. TEE was delayed due to respiratory status. hypoxia worsened on 12/25 so pulm consulted with CXR showing new effusions and atelectasis as well as infiltrates. bronch'd again 12/26 for persistent mucous plugging.  Patient also had a CT chest performed on 01/05/2023 which confirmed moderate bilateral effusions.  Patient responded well with diuresis.  On respiratory status improved.  Patient underwent a TEE on 12/28/2022 which finding showed mild aortic valve endocarditis without significant valvular dysfunction.  Infectious Disease recommendation was to continue with IV cefazolin 2 g every 12 hours for 6 week therapy and date being 01/31/2023.  Patient also was seen by Interventional Radiology team who performed a bilateral thoracentesis on 01/07/2023.  Patient had overall improvement of the respiratory function and was weaned down on oxygen support and transferred to the general medical for on 01/07/2023.   Patient was evaluated by Physical and Occupational therapy and recommendation was for subacute rehab.  Infectious Disease did not plan to follow as outpatient given short duration of therapy after discharge and given the patient is from elsewhere.  Infectious Disease does recommend echo after completion of IV antibiotics.  Outpatient Echo was ordered by Infectious Disease.  Given acute kidney injury still though was recovering nephrology recommended that patient have tunneled central venous line rather than PICC.  Tunneled central venous line was placed by IR on 1/13.  Did recommend that patient have outpatient CT chest and PFTs in 6-8 weeks and follow-up with pulmonology for outpatient sleep study.  She was continue with BiPAP q.h.s. for now at rehab until having outpatient sleep study.  Discharged stable condition to rehab on 01/13.