Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Tachypnoea, Troponin increased, Wheezing
Clinical narrative: Discharge Provider: No attending providers found Primary Care Provider at Discharge: PA-C Admission Date: 7/2/2022 Discharge Date: 7/11/2022  PRESENTING PROBLEM: Acute on chronic respiratory failure Pneumonia due to COVID-19 virus   HOSPITAL COURSE: The patient is a very pleasant 75-year-old gentleman with multiple medical problems presents to the ER with complaints of shortness of breath.  Patient is a very poor historian and additional information obtained from chart review and nursing.  Patient states that he was at a facility from February to March for chronic obstructive pulmonary disease.  Patient does not know if he was in the intensive care unit or intubated.  Patient states that he had a recent visit in the beginning of the month for 1 week for chronic obstructive pulmonary disease exacerbation.  Patient states that he is COVID vaccinated +1 booster.  He denies ever having COVID before.  Patient states that he lives in a house with multiple family members and extended family members however he is only 1 who is sick.  Patient states that he got short of breath today and could not catch his breath.  Patient is on baseline 3 L of oxygen.  On arrival to the ER patient was tachypneic hypoxic and having wheezing.  Patient was given breathing treatments steroids.  COVID test was positive.  Patient was initiated on remdesivir.  CTA of chest was negative for PE or pneumonia.  Patient improved on exam but still has wheezing and needs close monitoring and is still exceeding his baseline oxygen needs.   7/6/2022: Patient improved on BiPAP:  ABGs were consistent with respiratory acidosis; elevated troponins secondary to demand ischemia; Echocardiogram:The left ventricular ejection fraction is 62%. The left ventricle is normal in size. No regional wall motion abnormalities noted. The right ventricle is normal size. The right ventricular systolic function is normal. No significant valvular pathology. Patient improved with IV corticosteroids and DuoNebs around the clock.  Component was consistent of chronic obstructive pulmonary disease exacerbation superimposed by COVID-19 infection   7/7/2022: Patient continues BiPAP overnight with improvement of respiratory status:  CTA of the chest shows pulmonary nodule which will need follow-up outpatient.  Patient continue to improve with treatment plan of breathing treatments and corticosteroids   7/8/2022 Acute on chronic respiratory failure:  Multifactorial chronic obstructive pulmonary disease exacerbation, COVID-19 infection, preserved heart failure; Solu-Medrol was decreased to 40 mg IV q.12 hours do nebs 4 times a day with Pulmicort 0.5 mg 2 times a day; patient continued to improve with treatment plan.  Patient at this time refuses to go to skilled nursing facility for strengthening conditioning due to financial burdens.   7/9/2022 Acute on chronic respiratory failure:  Multifactorial chronic obstructive pulmonary disorder exacerbation chronic obstructive pulmonary disease infection preserved heart failure:  Transitions steroids to prednisone orally 40 mg daily, breathing treatments DuoNebs q.6 hours with Pulmicort 0.5 mg inhalation 2 times a day; give 1 dose of 0.5 mg Bumex IV push with significant diuresis.  Discussed during round patient would benefit from BiPAP at home due to frequent hospitalizations of chronic obstructive pulmonary disease exacerbation with component of preserved heart failure.  Social work and case management currently working on getting BiPAP/NIV for home with home care.  Personal medical opinion if patient goes home without home BiPAP will be readmitted with exacerbation of acute on chronic respiratory failure.   7/10/2022 Patient had RT 34° performed last night qualifies for BiPAP :patient currently not short of breath on baseline oxygen of 2 L or short of breath with exertion continue oral corticosteroids and DuoNebs and Pulmicort at this time.  Once patient is able to have authorization for BiPAP patient will be need to be sent home with BiPAP and prior authorization for trilogy for end-stage chronic obstructive pulmonary disease         7/11:  Patient has continued to do well.  He is stable for discharge.  BiPAP was arranged.  Patient will continue with therapy as outlined above including prednisone taper.  Patient advised to follow-up with primary care physician this week.   It is noted that patient has significant CO2 retention, and needs BiPAP to prevent developing CO2 narcosis.  He will need to wear BiPAP at nighttime when he sleeps.  Would also recommend he wear when he naps.