Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: White blood cell count increased
Clinical narrative: COVID+12/13/2022.  Vaccination Status -J&J x1   Discharge Date: Jan 13, 2023 Discharge Provider: MD Primary Care Provider : No primary care provider on file. None  Admission Date: 12/13/2022 Active Hospital Problems   Diagnosis Date Noted POA ? Necrotizing Pneumonia of right lower lobe due to MDR Pseudomonas  11/22/2022 Yes ? Chronic respiratory failure with hypoxia  11/22/2022 Yes ? Chronic combined systolic and diastolic heart failure 11/18/2013 Yes ? COPD (chronic obstructive pulmonary disease) 07/29/2013 Yes ? Coronary artery disease involving native coronary artery of native heart with other form of angina pectoris  04/15/2013 Yes ? Counseling regarding advance care planning and goals of care 12/16/2022 Unknown ? Chronic anemia 12/14/2022 Unknown ? Unspecified severe protein-calorie malnutrition  07/12/2021 Yes ? Persistent atrial fibrillation  03/11/2021 Yes ? Type 2 diabetes mellitus with circulatory disorder, without long-term current use of insulin  06/04/2019 Yes ? History of bladder cancer 06/04/2019 Yes ? Essential hypertension    Details of Hospital Stay PRESENTING PROBLEM: Pneumonia of right lower lobe due to Pseudomonas species    HOSPITAL COURSE: Per ICU transfer summary:" Patient is a 71 y/o male w/pmhx significant for DMII, HTN, HLD, CAD, atrial fibrillation on Xarelto, ischemic cardiomyopathy s/p ICD placement, combined heart failure with EF of 25%, vascular dementia, depression, anxiety, chronic pain, history of bladder cancer & COPD. Also noted to have chronic hypoxic respiratory failure for which he utilizes 3L nasal cannula continuously. He follows with pulmonology outpatient in regards to long standing RLL cystic/cavitary lesion which has been monitored with serial imaging (felt to have low likelihood of malignancy).   Patient has had two recent hospitalizations (9/28-11/4, 11/21-12/4) related to acute on chronic respiratory failure secondary to necrotizing Pseudomonas which was MDR. ID was involved during these hospitalizations and assisted with multiple changes in antimicrobial therapy. Patient last completed Zerbaxa, 7 day therapy through 11/28. He then was to have follow up imaging of his thorax in 1 month from 11/28. He was also found to be COVID positive during his second hospitalization 11/22 for which he received steroids/Remdesivir.    Patient was seen by his PCP 12/13 for hospital discharge follow up. It was noted patient had been immobile & confined to his recliner chair secondary to weakness with 2-3 recent falls. Patient reports weakness started a few days ago. He otherwise feels his breathing has been at baseline. He has a chronic cough with white phlegm that is largely unchanged. No known fevers, CP, abdominal pain, N/V/D. He has had reduced appetite. It appears his Coreg and lasix have been on hold as of late due to low blood pressures but he has continued to take Entresto. He notably has had trouble tolerating his cardiac meds due to hypotension. He ultimately presented to the ED the late evening of 12/13 after sustaining a fall in the bathroom at which time he hit his head and was unable to get up.   Upon arrival to the ED, patient was tachypneic and tachycardic and placed on Bipap. BP noted to be low at 81/30. While in ED, patient able to be weaned to NC at baseline oxygen level. Bedside ultrasound noted collapsible IVC. Workup significant for: WBC 18.02, BNP 2070, Troponins flat at 38 & 37, sodium 132, lactic 2.3, COVID-19+ again. Head CT negative. CT thorax with persistent/worsening RLL necrotizing findings. Patient received Cefepime & Azithromycin, as well as 2L IVF. With persistent hypotension, patient was placed on NE & he was admitted to ICU for further care.  Modest Norepi dose since arrival 12/13 through 12/17AM - weaned off for ~12 hours but recurrent hypotension prompted resuming Norepi at low-dose.  Palliative Care consulted, assisting with goals of care - continuing aggressive medical management with supportive respiratory care, hemodynamic support, antibiotic courses.  Attempting further aggressive CPT, 3%NaCl.  Hemodynamics stabilized. He was taken off of Norepi on 12/17 afternoon and was transferred out of ICU 12/18. He continued to require 3lpm NC of oxygen. ID recommended Zerbaxa 3 grams Q8hrs x6 weeks (EOT 1/25/23) with repeat CT chest in 4 weeks.    Patient had borderline hypotension requiring holding Entresto and lasix.  Starting 12/31 patient began to complain of increasing sputum production and shortness of breath as well as chills. Given patient's complaints of feeling worse, upper respiratory symptoms, Infectious Disease was contacted to re-evaluate the patient on 01/01.  Further infectious workup was pursued with additional fungal tests, which resulted negative. Karius was sent 1/6 and turned out negative Pulmonology was consulted for possible bronchoscopy, but felt patient is too high risk at this time. Could consider outpatient in a few weeks. PICC line was placed 1/6. Cardiology was consulted to assist in management. BP eventually improved and stabilized. Lasix was restarted with no recurrence of hypotension, producing good urine output. Patient continues to c/o dyspnea, chest discomfort but stable for the last week and his exercise tolerance is increasing. Patient was discharged home and home antibiotic infusion/visiting nurses was arranged. Patient was advised close follow up with PCP, Infectious disease, and Cardiology.   CONSULTS: Infectious Disease  Pulmonology Cardiology Urology  Palliative Care  PM&R