Age: 48.0
Sex: F
Vaccine: COVID19
Symptoms: Heart valve stenosis, Hepatic enzyme increased, Hypercapnia, Hypervolaemia, Hypoxia
Clinical narrative: "Hospitalized (4.17.22 -4.19.22); COVID-19 positive (4.17.22); fully vaccinated PLUS Booster - moderna x3 d/c summary: BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: PA-C Admission Date: 4/17/2022 Discharge Date: Apr 19, 2022   Active Hospital Problems   Diagnosis Date Noted POA ? Acute on chronic respiratory failure with hypoxia and hypercapnia    Discharge Disposition:  home or self care   Active Issues Requiring Follow-up:  - follow up with PCP: CHF exacerbation, re-evaluate lasix regimen following continued diuresis, COPD, and COVID follow up  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute on chronic respiratory failure with hypoxia and hypercapnia [J96.21, J96.22]   HOSPITAL COURSE: Patient is a 49 y.o. female with a PMH of T2DM, COPD on 4L Baseline, OSA who presented to the ED due to worsening generalized fatigue, cough over the past week found to be requiring 6L of O2 and fluid overloaded on exam., found to be Covid positive, with CXR revealing GGO transferred to Hospital for further mangement. Patient was treated with diuresis for heart failure exacerbation, duonebs and azithromycin for coverage for COPD exacerbation and decadron for COVID 19 pneumonia diagnosis. Patient was evaluated with updated echo inpatient, showing stable findings with updated EF of 65% with mild valvular stenosis and mild aortic regurgitation compared to Oct 2021. Following IV diuresis, patient's clinical status improved and her oxygen requirements improved back to baseline 4L both at rest and with ambulation. During presentation, patient had an AKI that improved with diuresis supporting cardiorenal etiology. Patient was discharged with an increased diuresis regimen from her previously daily home dosing. Prior to discharge on 4/19, patient was counseled on resources with COVID-at-home program for follow-up. However, she declined service and expressed preference to quarantine at home and call her PCP for close outpatient follow up. Consult Orders (From admission, onward)                IP CONSULT TO DIABETES & ENDOCRINOLOGY      Provider:  Diabetes And Endocrinology INPATIENT PROCEDURES: none BP 178/82  | Pulse 52  | Temp 36.9 °C (Oral)  | Resp 16  | Ht 1.626 m  | Wt 105 kg  | SpO2 98%  | BMI 39.73 kg/m²  FIO2 (%): 35 % Physical Exam Constitutional:      Appearance: She is obese.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal. No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: Edema present.     Left lower leg: Edema (mild B/l LE Edema 1-2+, improving on discharge) present.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: No erythema, lesion or rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.    4/17/22 H&P:  CHIEF COMPLAINT: Acute on chronic respiratory failure with hypoxia and hypercapnia  ASSESSMENT / PLAN: Patient is a 49 y.o. female with a PMH of T2DM, COPD on 4L Baseline, OSA who presented to the ED due to worsening generalized fatigue, cough over the past week found to be requiring 6L of O2 and fluid overloaded on exam, found to be Covid positive, with CXR revealing GGO transferred to Hospital for further mangement.      #Acute on Chronic Hypoxic Hypercapnic Respiratory Failure-Multifactorial Pt with increasing O2 requirements from baseline 4L, currently on 7L NC. Etiology of patients respiratory failure likely multifactorial in the setting of CHF exacerbation, COPD exacerbation, and Covid Pneumonia with GGO notable on CXR with b/l infiltrates noted. Will plan on managing each condition as written below.  Plan: -on 7L NC, wean as able -other management as noted below #Acute on Chronic Diastolic Heart Failure Exacerbation BNP elevated at 7,012 on arrival. CXR with b/l GGO notable, with physical exam consistent with fluid overload. Now s/p 40 IV lasix at hospital with significant response and good UOP. Bedside ultrasound revealed a IVC 2-2.5cm with minimal respiratory variation consistent with fluid overload. On home lasix 20 daily, will plan on initiating 40 IV Lasix BID. Plan: -Echo ordered -DSW, strict IO/s -Lasix 40 IV BID #COPD Exacerbation- On 4L at baseline Notable wheezing on exam, in the setting of covid 19 pneumonia and fluid overload may have triggered pt into exacerbation.  Plan: -Decadron 6mg daily -Azithromycin -Scheduled duonebs -Singulair, Spiriva, Flovent  #Covid-19 Pneumonia Patient Vaccinatedx3. With increased O2 requirements currently on HFNC , will plan on treating at this time with decadron 10d course. Will hold off on Remdesivir in the setting of AKI and elevated LFT's. Cannot rule out superimposed bacterial infection with increased sputum production and change in color. Will order nfectious workup with sputum cx, legionella and strep pneumo, await findings prior to broadening abx. Plan: -Wean O2 as able, goal O2 88-92 -Decadron 6mg daily for 10d course -Legionella step urine ag -Sputum cx ordered #AKI Baseline Creatinine near 0.95. Cr on presentation 2.08. Significant response to 40 IV lasix, with improvement in kidney function signals likely cardiorenal syndrome in the setting of fluid overload. Will plan on Continuing to monitor response to diuresis at this time. Plan: -BMP Q8 -Continue diuresis #Hyponetremia Likely Hypervolemic Hyponatremia. Will plan on diuresis at this time, fluid restriction. Plan: -Diuresis, fluid restriction  -BMP q8 #T2DM On Lantus 25 units and Metformin 1G BID daily and novolog 10 w/ meals. Will polan on initiating home dose Lantus, with MDC, close monitoring of Blood sugars. Plan: -Lantus 25, Moderate dose corrective #Elevated Liver Enzymes AST 261, ALT 107, T bili 0.2, ALK Phos 359 on arrival. Known hx of hepatic steatosis seen on imaging. Elevated enzymes from baseline currently, likely in the setting of hepatic congestion w/ fluid overload, and covid infection. Plan: -Daily CMP -IF worsening can consider RUQ u/s   #Microcytic Anemia Baseline Hgb near 13. Currently 11.5. Will plan on evaluating with iron studies Plan: -Ferritin, Iron studies pending #Fibromyaligia -home lyrica #Bipolar Disorder -Lamictal, Lexapro #Insomnia -Home remeron #HTN On home norvasc Plan: -Will hold off initiating home med now in he setting of diuresis, BP remains stable