Age: 57.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Orthostatic hypotension, PCO2 increased, Positive airway pressure therapy, Pyuria, Respiratory acidosis
Clinical narrative: Hospitalized (2.27.22 - 3.3.22);  COVID-19 positive (2.27.22); Fully Vaccinated PLUS booster Discharge Provider:  MD Primary Care Provider:  MD Admission Date: 2/27/2022 Discharge Date: Mar 3, 2022 DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Vasovagal syncope [R55] Somnolence [R40.0] Hypoxia, sleep related [G47.34] Acute respiratory failure with hypoxia and hypercapnia (HCC) [J96.01, J96.02]   DC summary edit pending   HOSPITAL COURSE:   A 57 y.o. female with h/o COPD, T2DM, HTN, HLD, GERD/DUD, IBS, migraines, bipolar disorder and chronic pain with opioid dependence, presenting to the Butterworth ER on 2/27 following a syncopal episode.  She was laying in bed today nursing chronic back pain, when she became nauseous and felt the need to vomit and have a BM.  She then suffered a syncopal episode, whereafter she rapidly regained consciousness and immediately returned to baseline mentation.  She did endorse some left-sided neck pain after her fall.  Family noted to the ED provider that she has been feeling poorly in recent days and, as such, is not eating/drinking normally per her baseline.     In the ER, she was afebrile, hypotensive, with normal HR, tachypnic and hypoxic to 85% on baseline RA.  Initial labs were notable for AGMA, leukocytosis, hypoalbuminemia.  Serial VBG showed mild respiratory acidosis with pCO2 in 50s.  COVID screen was positive and she is vaccinated.  EKG shows NSR.  CTH and CTCS negative for acute processes.  CXR was clear.  She was treated with Zofran, Decadron and IV fluids, and admission to IM was requested for management of acute hypoxic and hypercapnic respiratory failure.  BiPAP trial in setting of persistent lethargy and persistently elevated pCO2 with respiratory acidosis was started.  CT of the abdomen and pelvis was performed which showed no obvious source of her leukocytosis and abdominal pain.  She was transferred to Hospital to the hospitalist service.   Hypotension, asx HTN by hx HOLD lisinopril 10 and prazosin 1 HS at DC given presenting and persistent hypotension with resumption only after verifying BPs high enough to support DASH diet at discharge   Acute hypoxic and hypercapnic respiratory failure Attributed to polypharmacy w/ sedating meds including opioid, COVID infection, poor oral intake, and continued anti-HTNs COVID + COPD Hypoxic to 85% on baseline RA VBG w/ hypercapnia and mild respiratory acidosis CXR clear BiPAP trial in ER given persistent lethargy and hypercapnia w/ repeat VBG w/ improvement in both; was still very sleepy. Dexamethasone 6 d with plan to stop at DC given no support for this indication INH inhalers Sx mngt, supportive care, encourage IS use D-dimer not elevated   Syncope w/ collapse Presumed vasovagal v orthostatic hypotension due to decreased oral intake, continued anti-HTN med use, illness w/ Covid infection Neck pain possible muscle strain from fall CT head and CT cervical spine with no acute processes   Encephalopathy, acute toxic metabolic: Resolved Likely secondary to polypharmacy esp w/ opioid, hypercapnic respiratory failure, and infection Avoid sedating meds/doses Telemetry and continuous pulse ox   AGMA: Resolved IVFs now off so verify taking oral to avoid return of si/sx that led to admission   Bipolar disorder Chronic pain with opioid dependence Abdominal pain CT AP w/o clear source of pain; chronic opioid not likely helpful Tylenol w/ Suboxone in lieu of buprenorphine 8 PO q8 for past year when home Med effect noted despite pt more alert 3/2/22 - Monitor for S/Sx of opioid withdrawal, consider Addiction Med consult for re-dosing if needed.    SIRS, no clear source for sepsis Likely reactive and due to acute viral illness Pyuria w/ mod leuks and few bacteria, no growth from ctx sent from ER. CXR and CT AP without e/o acute processes Hold on abx for now, but monitor for infectious si/sx   DMII, A1c 6.8 Hold metformin No indication for insulin so canceled   HLD Aspirin and statin continued   GERD/PUD PPI continued   VTE ppx:  High risk so Lovenox SQ; note low wt so may need dose adjust over time Diet: Consistent carb Partial code, desires intubation and ventilation if needed but no CPR   DC home 3/3/22 given consistently awake, alert and not intermittently somnolent w/ hypoxia or respiratory insufficiency to suggest hypercapnia   The following was provided in writing at discharge:   Opioid pain medicine, buprenorphine and other sedating medicine Do not take more than scribed given risk of death by doing so Work with your doctor on pain management strategies that do not involve opioid given this risk Taking opioid medications during time of illness (Covid infection), not consuming enough food/fluids (dehydrated), and continuing meds such as anti-hypertensives leading to low blood pressures can come together leading to decreased levels of consciousness and hospitalization. Work with your doctor on safe medicine use, especially when ill or not eating/drinking enough.   Your dose of Lyrica was reduced while here, from 200 mg twice daily to 150 mg twice daily in the setting of excess sedation You did very well with this dose reduction. Consider lowering your dose so you take the lowest effective dose of medicines like these No adjustment to this medicine and its dose was made at discharge   Hypotension HOLD lisinopril and prazosin These medicines lower blood pressure.  Your pressures were too soft during your stay to support safe use at discharge Keep them near, however as you and your doctor may decide they need to be restarted in the future We recommend your blood pressures are at least 130/80