Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Metabolic acidosis, Metabolic function test abnormal, Multipathogen PCR test, N-terminal prohormone brain natriuretic peptide increased, Nasal congestion
Clinical narrative: Chief Complaint   increasing shortness of breath since thursday, 69% with good pleth in traige. placed on 15L NRB and moved to R4  History of Present Illness      70-year-old gentleman with history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and GERD who presents ED for evaluation of shortness of breath and congestion.  Patient states he started feeling generally unwell 4 days ago.  Having increased shortness of breath.  Reports some nasal congestion and sinus pressure.  Having generalized weakness, fatigue and malaise.  Mild generalized body aches. Denying any sore throat, chest pain or palpitations.  No abdominal pain, nausea, vomiting or diarrhea.  No lower extremity pain or swelling.  Has been vaccinated for COVID-19, has not received influenza vaccine as of yet.  He does not smoke.  No history of underlying chronic lung disease although he states he frequently gets pneumonia.  Review of Systems        Constitutional: Subjective fevers.  Weakness, fatigue, malaise.    ENMT: Nasal congestion and sinus pressure.  No sore throat.    Respiratory: Increased shortness of breath.  No significant cough.  No hemoptysis.    Cardiovascular: No chest pain. No palpitations. No peripheral edema.    Gastrointestinal: No abdominal pain. No nausea. No vomiting. No diarrhea    Genitourinary: No dysuria.     Musculoskeletal: No back pain. No calf pain/swelling.   Neurological: No headaches. No dizziness. No extremity numbness or tingling.    Psychiatric: No substance abuse.    Hematology: No hx of DVT/PE.    Additional ROS: All other systems reviewed and are negative.   Physical Exam  Vitals & Measurements  T: 36.7 °C  HR: 85  RR: 33  BP: 146/86  SpO2: 98%  WT: 78.7 kg      General: Alert, no acute distress, speaking in full sentences, no significant respiratory distress.  Skin: Warm, dry, no rash.   Head: Normocephalic, atraumatic.   Neck: Supple. Trachea midline, no JVD  Eye: Pupils are equal, round, and reactive to light, normal conjunctiva, EOMI  Ears, nose, mouth, and throat: Oral mucosa moist, no pharyngeal erythema or exudate.  No oral pharyngeal edema.  Airway patent. Tolerating secretions.  Cardiovascular: Regular rate and rhythm, no murmur, normal peripheral perfusion, no edema. Bilateral radial and DP pulses present.  Respiratory: Mildly tachypneic. Respirations are nonlabored. Able to speak in full sentences. Lung sounds are clear bilateral without wheezing crackles or rails audible.  Chest wall: Symmetric chest rise. No deformities.  Musculoskeletal: Normal ROM and strength throughout, no swelling or tenderness of the lower extremities  Gastrointestinal: Soft, nondistended, nontender, normal bowel sounds,     Neurological: Alert and oriented to person, place, time, and situation. No focal deficits. Normal speech.   Psychiatric: Cooperative.  Calm.  Normal judgment.        Medical Decision Making        71-year-old gentleman with history of IDDM 2, HTN and GERD, HLD who presents with shortness of breath. Has had increasing shortness of breath for the last few days as well as congestion, subjective fevers, generalized weakness, fatigue, malaise and body aches. Patient hypoxic at 69% on room air upon arrival, slightly tachypneic however not exhibiting signs of respiratory distress. Was placed on 15 L via nonrebreather and oxygenation quickly improved into the 90 percentile. He was then transitioned to a nasal cannula at 6 L however had desaturations back into the 80% requiring 10 L via simple facemask to maintain oxygen saturations in the mid to upper 90%. Continued with tachypnea while in the ED. Afebrile with normal heart rate and some hypertension is present. His EKG showed normal sinus rhythm without any ischemic changes present. Laboratory evaluation with CBC showing normal WBC, CMP with mild hyponatremia and mild anion gap acidosis. Initial lactic acid of 2.2, rising to 2.4 on 2-hour repeat. His initial troponin was 25, repeat troponin is pending. NT proBNP elevated minimally at 168, no previous for comparison. VBG showed a CO2 of 36 with a pH of 7.4. His rapid Covid and rapid flu were negative. Chest radiograph without any acute cardiopulmonary findings. CT pulmonary angiography of the chest was obtained which showed evidence of a nonocclusive right upper lobe segmental pulmonary embolism and a pulmonary artery branch point as well as bilateral groundglass opacities concerning for infectious or inflammatory process. Given his hypoxia, he received a DuoNeb without any change in his symptoms. Given patient's symptomatic PE, patient started on heparin infusion. Patient COVID-19 PCR returned positive.  All other tests on the RPP were not detected.  Is positive Covid status is consistent with his presentation with hypoxia groundglass opacities on CT as well as his comfortable appearance in the setting of rather profound hypoxia.  I have ordered for 2 mg of dexamethasone to be administered.  Family medicine is agreeable to meet this patient today will be admitted to the stepdown unit for further respiratory support in the setting of acute hypoxic respiratory failure with COVID-19 viral infection and nonocclusive segmental pulmonary embolism.          Assessment/Plan      1. Acute respiratory failure with hypoxia    2. Pulmonary embolism    3. COVID-19 virus infection     Orders:   dexAMETHAsone, 10 mg = 1 mL, form: Injection, Slow IV Push, Once, Routine, first dose 10/24/21 23:00:00 CDT, Physician Stop, stop date 10/24/21 23:00:00 CDT  heparin, Nomogram, form: Injection, IV Push, As Indicated PRN for Other; See comments, first dose 10/24/21 21:49:00 CDT  heparin 25,000 units, Total volume (mL): 250, IV Soln, IV, TITRATE - See Nomogram Task for inital infusion ra, Start date: 10/24/21 21:49:00 CDT  CT Chest PE Protocol  Heparin Nomogram - Dosage Titration Orders  Heparin Nomogram - Notify Physician  Heparin Nomogram - Unfractionated Heparin Assay orders  Heparin Nomogram - Use Admission Weight  Platelet Count  XR Chest Portable  Disposition: Guarded, admitted to family medicine, stepdown unit,