Age: 58.0
Sex: M
Vaccine: COVID19
Symptoms: Lymphopenia, Mechanical ventilation, Nothing by mouth order, Oedema peripheral, Oral candidiasis
Clinical narrative: "Hospitalized (3.21.22 w ICU, transferred4/1/22- 4/23/22); COVID-19 positive (4.14.22);  fully vaccinated PLUS Booster -pfizer x3 d/c summary:  Attestation signed by MD at 4/23/2022  3:49 PM  I have personally interviewed and examined the patient on 4/23/2022 . Management was discussed with Dr.  (resident). I agree with the documented findings and plan of care in his/her note.     Brief exam:   Gen: NAD, awake, mouths words  HEENT: OP clear, MMM, no LAD  Neck: Supple, trachea midline, 8.0 cuffed trach, on t-piece, back pressure with a few seconds of finger occlusion  Chest: scattered ronchi on the L  CV: RRR, nl s1/s2, no m/r/g  Abd: +BS, Soft NT/ND, no organomegaly  Ext: No c/c/e  Neuro: AAOx3, moves all extremities spontaneously  Skin: Warm and dry, no rashes.   Psych: Normal affect and mood.  Cooperative.        Brief history and medical decision making: 59 yo M with HTN, R pneumonectomy 2/2 thymoma complicated by Good syndrome, DVT on AC, recent covid-19 pna, admitted for hypoxic resp failure. Now s/p trach. Tolerating t-piece but requires pressure support at night. Has not tolerated speaking valve. Back pressure with finger occlusion. Stil tenacious secretions. Cont vent weaning. Transfer   today. Unable to get a hold of receiving physician despite mulitple calls from our team (Dr.) but spoke with charge nurse at Select and care manager here. Both said pt can still transfer. He is hemodynamically stable upon discharge. MD   BRIEF OVERVIEW: Discharge Provider:  DO Primary Care Provider at Discharge:  DO Admission Date: 4/1/2022         Discharge Date: 4/22/2022  Active Hospital Problems   Diagnosis Date Noted POA  Hypogammaglobulinemia (HCC) 04/15/2022 Yes  Pyuria 04/15/2022 Unknown  COVID-19 04/15/2022 Unknown  Acute respiratory failure with hypoxia (HCC) 04/02/2022 Unknown  Respiratory failure (HCC)    Discharge Disposition: long term acute care   Active Issues Requiring Follow-up:  - Restarting Xarelto for DVT. Currently holding heparin for traumatic foley bleed.   - Immunology Recs: Order IVIG 35 grams on 4/30/22  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM:       Respiratory failure (HCC) [J96.90] Sepsis (HCC) [A41.9] Acute respiratory failure with hypoxia (HCC) [J96.01] HOSPITAL COURSE: a 59 y.o. male with PMHx of HTN, pneumonectomy in feb 2020 secondary to an adherent Thymoma, recent hospitalization due to covid-19 pneumonia in 2/2022 complicated by DVT on xarelto who presented as a readmission to OSH after having worsening shortness of breath and hypoxic respiratory failure requiring intubation 3/25 thought now due to post covid ILD.  Due to continued hypoxia requiring ongoing ventilation patient transferred for lung transplant evaluation. Lung transplant team thought there is chance for improvement, made recommendations of prolonger steroid course and weaning vent settings as able. He was not a lung transplant candidate. He was diagnosed with Good Syndrome by immunology for absent B cells and hypogammablobulinemia. Immunology recommending q4 week IVIG infusions and received IVIG on 4/2. Pt was transitioned to trach on 4/6. Heparin gtt was initiated for his recent DVT. He had a minor tracheostomy bleed that was monitored and stabilized. He retested positive for COVID on 4/14, positive nucleocapsid antibody which was indicative of reinfection. He also developed a VAP with fever and worsening CXR. He completed treatment for VAP and has continued to improve from a respiratory standpoint. He t-pieced during the day and required ventilatory support at night. He had a traumatic foley that was removed by Urology.  His subcutaneous heparin was held while he had been having some bleeding from his with catheter.  He remained medically stable for discharge .  CONSULTS / RECOMMENDATION: Immunology: IVIG will need to be ordered on 4/30/22 by the primary team Cardiothoracic Crit Care: Patient was not deemed appropriate transplant candidate. INPATIENT PROCEDURES: Tracheostomy on 4/6/22 corpak placement 4/2/22 Bronchoscopy on 4/14/22   BP 129/96  | Pulse 116  | Temp 37.6 °C (Oral)  | Resp 27  | Ht 1.85 m  | Wt 78.3 kg  | SpO2 98%  | BMI 22.88 kg/m²  FIO2 (%): 35 % Physical Exam Constitutional:  General: He is not in acute distress.    Appearance: He is not diaphoretic.  HENT:   Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:    Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Neck:    Comments: Tracheostomy site clean and dry Cardiovascular:    Rate and Rhythm: Regular rhythm. Tachycardia present.  Pulmonary:    Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No stridor. Rhonchi and rales present.     Comments: Decreased breath sounds on the right Abdominal:    General: There is no distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:    Right lower leg: No edema.     Left lower leg: No edema.  Skin:   General: Skin is warm and dry.  Neurological:    Mental Status: He is alert.     Comments: Moves all extremities   4/1/22 Med Critical Care H&P:  I have personally interviewed and examined the patient on 4/1/2022. Management was discussed with Dr.  I agree with the documented findings and plan of care in his/her note.  Brief exam:  Intubated sedated.  Absent breath sounds right lung.  Coarse breath sounds left lung.  Abdomen soft.     Brief history and medical decision making:  59-year-old male with history of pneumonectomy secondary to thymoma, hospitalization secondary to COVID-19 pneumonia in February 2022 complicated with DVT and readmission to outside hospital for worsening hypoxic respiratory failure.  Intubated on 03/25.  Continued to have hypoxia requiring ongoing mechanical ventilation patient was transferred to intensive care unit for lung transplant evaluation.     - Acute hypoxic Respiratory failure - post COVID in patient with hx of right pneumonectomy. Possibly secondary to organizing pneumonia or developing fibrosis post COVID.   Patient had been on steroids and per report he had to be readmitted the day after he weaned off his last prednisone taper.  Has been restarted on high-dose of steroids currently being weaned down to 40 mg daily prednisone.  Continue 40 mg of prednisone for now.  Start PJP prophylaxis again.  He also had a bronchoscopy at outside hospital with negative infectious workup.  Completed 8 days of cefepime. Holding off of antibiotics at this time.  Per OSH documentation -  3/22 Strep pneumo & Legionella Ur Ag => -VE x2 Resp viral panel (RSV, Influ A&B, Parainflu 1-4, adenovirus, Meteapneumo) => -VE Fungitell x2 => -VE serum Galactomannan => -VE (03/22, 03/28) fungal precipitins => -VE Blood cx: No Growth x2   3/23 sputum cx: Normal respiratory flora 03/23 Histo U Ag -VE 03/26  Resp cx:Normal respiratory flora    BAL fungal cx: No growth to date. BAL anaerobic cx: No growth to date. BAL Galactomannan -VE (03/26) PJP BAL PCR -VE   Unclear volume status at this time.  Will continue diuresis to aim for net negative.  If no significant improvement and may consider repeat CT.     Given single lung will aim for a tidal volume of 320 mL - 4 mL/kilograms ideal body weight to avoid over ventilation and lung injury.  Deep sedation for vent synchrony at this time.  Wean PEEP and FiO2 as able.  Holding off paralytics at this time.  Lung transplant team will evaluate in the morning.    Monitor H/H - transfuse for goal of 7. No clear source of bleeding at this time.  Will check hemolysis labs.  Will hold anticoagulation that he has been on for DVT for now.  If no further bleeding or drop in hemoglobin may consider starting heparin drip.  CHIEF COMPLAINT:    Respiratory failure (HCC) ASSESSMENT / PLAN: a 59 y.o. male with PMHx of HTN, recent COVID pna hospitalization in 2/22-3/11 on O2, and pneumonectomy secondary to Thymoma in 2020 here for a lung transplant evaluation. He was recently hospitalized for COVID Pna in 2/13-2/19. He was found to have DVT and placed on Xarelto. He was discharged where he was discharged on 3/11/22 with supplemental O2. He remained short of breath since that time and eventually started satting in 70s on 3L NC. He had worsening dyspnea and presented to hospital on 3/22. New imaging showed ground glass changes in left lung compared to prior CT. Fungal workup negative. He had worsening respiratory status and failure of BiPap and subsequently intubated on 3/25/22. His vent settings showed increased need. Hospital declined eval for lung Trx.  contacted and case rejected (policy for post-covid lung trx eval), then contacted who accepted. He was transferred to  ICU for Lung Transplant Evaluation. AHRF ARDS Post-COVID ILD Hx of Pneumonectomy in 2020 due to Thymoma Fluid overload COVID dx in Feb 2022 (Covid boosted). Imaging shows ground glass changes in left lung compared to prior CT imaging. Infection unlikely given negative workup and recent abx (as below). Possible fluid overload status in this picture as well. ABG: pH 7.43, pCO2 56.8 Lactate 0.6 CXR: No right lung, left lung with diffuse airspace disease    Last Abx: 3/25: Azithro 3/29: Cefepime (2g TID) 4/1 micafungin d/c'd 4/1: Bactrim d/c'd (3/23-4/1) 3/23-3/26 Vanc   AC Pressure FIO2 (%): 50 % Type of Mechanical Vent: Hamilton Mechanical Rate: 30 breaths/min Inspiratory Pressure Above PEEP: 8 cmH2O PEEP (cm H2O): 8 cm H2O   RASS:  -5 Sedation: Fent 100, Prop 50 Pressors: None   Plan: - ABG q8 - Lung Transplant Evaluation - Prenisone 40mg daily (taper down) - Bactrim ppx on HOLD, consider alternative like Atovaquone - Lasix 40mg IV daily, consider increasing with fluid goal -1L - Duo neb q6 - Lung Protective settings: TV 300-320 - Obtain CT scan and bronch in next few days after diuresis Macrocytic Anemia Received 1unit pRBC  Hgb low at admit 6.3 CT Ab/pelvis 3/27 did not show acute bleed. May be caused by Bactrim (which is currently held), consider Atovaquone for ppx - Replace 1 unit pRBC, CBC after - CBC q8 - Reticulocyte count - Peripheral smear - LDH, Haptoglobin DVT Previously on Xarelto. Transitioned to Lovenox 50mg BID at Sparrow. - HOLD Lovenox 50mg BID given anemia HTN Home meds: Metoprolol 50mg BID, HCTZ 25/d - Hold home meds Nutrition - Obtain Corpak tomorrow - Consult to medical nutrition Oral Thrush - Oral care kit, will consider adding nystatin Lines: PICC, A-Line Tubes: ETT (3/25), Foley Diet: NPO GI Prophylaxis: Pepcid DVT Prophylaxis: Holding Lovenox due to anemia, previously on Lovenox 50mg BID Code Status: Full Unknown Disposition: ICU sedated and vented here for lung transplant evaluation HISTORY OF PRESENT ILLNESS: a 59 y.o. male with PMHx of HTN, recent COVID, and pneumonectomy secondary to Thymoma in March 2020 who presents to the  ICU as a transfer from hospital for Lung Transplant Evaluation.   He was recently hospitalized for COVID Pna in 2/13-2/19. He was found to have DVT and placed on Xarelto. He was discharged where he was discharged on 3/11/22 with supplemental O2. He remained short of breath since that time and eventually started satting in 70s on 3L NC.    He presented to hospital on 3/22. In ED was hypoxic to 80% on 8L NC, tachypneic. CT chest done showing resection of right lung and chronic right sided pleural effusion, worse ground glass changes in left lung compared to prior CT imaging. Was started on Vanc/Cefepime/Azithro/bactrim, prednisone. Required BiPAP for increased work of breathing. Transferred to ICU 3/24. Failed Bipap and intubated 3/25. 3/26 had bronch. Fungal workup negative and antibiotics, antifungals stopped. Continued steroids and diuresis. Noted to have Hgb 6.7 on 3/27 w/ no obvious signs of bleeding, CT Ab/pelvis done and 1 unit pRBCs given.    declined eval for lung Trx.  contacted and case rejected (policy for post-covid lung trx eval), then contacted  who accepted. He was transferred to ICU for Lung Transplant Evaluation.    On arrival patient is intubated and sedated. OBJECTIVE: BP (!) 95/49  | Pulse 98  | Temp 37.4 °C  | Resp (!) 38  | Ht 1.85 m  | Wt 87 kg  | SpO2 90%  | BMI 25.42 kg/m²  FIO2 (%): 50 % Physical Exam Constitutional:      Comments: Sedated  HENT:     Mouth/Throat:     Comments: Oral thrush Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Comments: Intubated Left lung rhonchi Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.  Musculoskeletal:     Right lower leg: Edema present.     Left lower leg: Edema present.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     Comments: Sedated