Age: 70.0
Sex: M
Vaccine: COVID19, FLUA4
Symptoms: Shock, Skin abrasion, Staphylococcus test negative, Staphylococcus test positive, Streptococcus test positive
Clinical narrative: Hospitalized (1.18.22 - still admitted currently); COVID-19 positive (12.26.21); fully vaccinated PLUS Booster - pfizer x3 1/18/22 H&P:  Attestation signed MD at 1/18/2022 10:07 PM MICU ATTENDING   I personally saw and examined the patient and discussed with the resident.  I assessed/reviewed this patient's hemodynamics, cardiopulmonary status, renal function, fluid balance, medications, labs, imaging, analog sedation, mental status (delirium), mobility, nutrition, glycemic control, line-tube-drain necessity, skin status, prophylaxis, disposition, patient/family concerns and daily goals.  I developed a detailed management plan on the basis of these assessments.   Brief exam:  Appears in acute distress, using accessory muscles of breathing, obtunded, distant heart sounds, abdomen soft nontender.   Brief History and Medical Decision-Making:  Patient is a 70-year-old with past medical history significant for obesity, stage II follicular lymphoma of the right neck, with partial response after 3 cycles of obinutuzumab and bendamustine chemotherapy; now s/p XRT,   COPD/asthma, and paralyzed left hemidiaphragm per sniff testing in 2016, hypertension, hyperlipidemia, ascending thoracic aortic aneurysm per CT scan in February 2021, and past tobacco abuse quit in 2012.   The patient is vaccinated for COVID-19 with COVID-19 booster on December 23rd.   The patient was diagnosed with COVID-19  December 26th with a chronic obstructive pulmonary disease exacerbation, he was given a brief course of prednisone and discharged from the emergency department.  The patient had another ER visit on January 6th with nausea vomiting and diarrhea and was discharged again to home.   Today patient's brother called primary care of his that he is in distress, an ambulance was called and he was found down in his house per EMS.  He was found to be severely discharge gold and with several decubitus ulcers.  Patient was given fluid resuscitation in the ER and started on vasopressors.     He was admitted to the intensive care unit with acute respiratory failure with hypoxia and shock.  The patient had worsening respiratory status and continue to be obtained ended in the intensive care unit.  Decision was made to intubate the patient for his worsening hypoxic respiratory failure and mental status.  Bronchoscopy and BAL done with cultures.   In light of his recent COVID-19 pneumonia, and persistent symptoms on CT scan as well as positive COVID-19 test today, recommend calling lab to run a cycle threshold on this PCR to assess if this is a false-positive.   Regarding his acute respiratory failure with hypoxia, ground-glass opacities noted bilaterally, concern for pulmonary embolism as well.  We will start the patient on empiric antibiotics, awaiting BAL, Solu-Medrol 2 times a day, add heparin with concerns of pulmonary embolism as his agree of hypoxia is not explained well with his infiltrates only.  Lower extremity Dopplers.   With his rhabdomyolysis, IV fluid given in the ER.  Repeat CPK.  Lactic acid trending down after fluid resuscitation. AKI appreat due to ATN & rhabdo, avoid nephrotoxins.    Brother was notified of his worsening status and intubation.   Principal Problem:   COVID Active Problems:   COVID-19 AKI Transaminitis CHIEF COMPLAINT: COVID    ASSESSMENT / PLAN: Patient is a 70 y.o. male with a past medical history of hypertension, hyperlipidemia, lymphoma next status post chemo and radiation, and recent COVID diagnosis on 12/26/2021, presented to the emergency department after being found down with altered mental status and shortness of breath.  Upon to be in shock requiring norepinephrine, transferred to the intensive care unit for further evaluation management   Shock - Undifferentiated Acute Hypoxic Respiratory Failure Differential of shock includes sepsis given recent COVID infection, though CT thorax without severe changes, procalcitonin elevated 0.81.  Cannot rule out obstructive PE as patient is at high risk for thrombosis given malignancy and COVID infection. CTA unable to be performed due to decreased GFR.  Initial lactic acid 4.5 Patient was subsequently intubated for airway protection Plan - Start broad-spectrum antibiotics, vancomycin and cefepime - Will send urine studies and film array for atypical pathogens - Echo to assess ejection fraction and signs of RV strain - Doppler ultrasounds all 4 extremities to rule out DVT.  Will empirically treat with heparin GTT - Blood cultures pending  - Pancultures from BAL pending - CRP elevated 161, will start methylprednisolone 80mg bid  - Repeat lactic acid level - Norepinephrine with goal MAP >65    Encephalopathy Likely multifactorial in etiology; uremia, toxic metabolic, vs septic.  Cannot rule out endocrinopathy especially with history of radiation to the neck CT head and cervical spine unremarkable Intubated for airway protection Plan - TSH - UDS - Consider MRI of brain pending results of labs  AKI Rhabdomyolysis Baseline normal renal function Creatinine on arrival 2.91 with BUN of 124. CK 2575 Etiology likely multifactorial from pigment induced AKI hypokalemia Plan - Urine studies urine sodium, osmolality, creatinine - Foley catheter in place for strict I/Os - Will trend with daily labs  Elevated LFTs CT thorax significant for cholelithiasis Total bilirubin elevated 2.7 Plan - Will order RUQ US to rule out choledocholithiasis versus cholangitis  Hypertension Plan - Holding home medications    Lines:  R IJ (1/18), R art line (1/18) Drains: Foley (1/18) Airway: ETT (1/18) Diet: NPO VTE Prophylaxis: Heparin gtt Code Status: Full unknown GI Prophylaxis: Not indicated at this time    Plan was discussed with attending, please see their attestation for further recommendations   DO Internal Medicine PGY1   HISTORY OF PRESENT ILLNESS: Patient is a 70 y.o. male with a history hypertension, hyperlipidemia, chronic obstructive pulmonary disease, lymphoma of the neck status post chemo radiation, presents after being found for approximately 2 days.  Who was recently diagnosed with COVID-19 pneumonia on 12/26, patient's point vaccinated and received booster dose.   In the emergency room patient was found to be hypoxic requiring nasal cannula oxygenation, and hypotensive.  Was given 2 L normal saline, vancomycin, Zosyn given concerns of sepsis.  As was not done and a CT head and CT cervical spine were ordered both were unremarkable.  Concern for PE was high given COVID and active malignancy but given AKI on labs a CTA was not performed.  A CT noncontrast of the chest showed diffuse ground-glass opacities.  Patient remained hypotensive after fluid resuscitation, requiring norepinephrine.  Labs remarkable for elevated creatinine kinase 2575, elevated total bilirubin, elevated renal function, liver function tests, lactic acid 4.5, blood cultures X 2 were obtained.   Patient was then transferred to the MICU for further evaluation and management.  Upon arrival he was found to not be able to protect his airway and was subsequently intubated.  His brother was called to update on situation.   Patient Active Problem List Diagnosis ? Tobacco abuse, in remission ? Pulmonary nodules ? Mild persistent asthma without complication ? Obstructive lung disease (generalized) (HCC) ? Dyslipidemia ? Diaphragmatic paralysis ? Tubulovillous adenoma ? Mental disability ? Primary hypertension ? Diverticulosis ? Grade 2 follicular lymphoma of lymph nodes of neck (HCC) ? Lymphoma of lymph nodes of head and neck region (HCC) ? Port-A-Cath in place ? Class 2 severe obesity due to excess calories with serious comorbidity and body mass index (BMI) of 37.0 to 37.9 in adult (HCC) ? COVID ? COVID-19 OBJECTIVE: BP 138/93  | Pulse 85  | Temp 37.1 °C  | Resp 21  | Ht 1.744 m  | Wt 96 kg  | SpO2 99%  | BMI 31.56 kg/m²  FIO2 (%): 100 % Physical Exam Vitals reviewed.  Constitutional:      Comments: Intubated, sedated  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Mouth/Throat:     Pharynx: Oropharynx is clear.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard.  Pulmonary:     Breath sounds: No stridor. Wheezing (Inspiratory, expiratory.  Right lung field) present. No rales.     Comments: Intubated Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    Comments: Multiple small excoriations across upper and lower extremities, without signs of infection    1/24/22 MICU progress note:  Attestation signed by Physician at 1/24/2022  3:20 PM MICU ATTENDING   I personally saw and examined the patient and discussed with the resident.  I assessed/reviewed this patient's hemodynamics, cardiopulmonary status, renal function, fluid balance, medications, labs, imaging, analog sedation, mental status (delirium), mobility, nutrition, glycemic control, line-tube-drain necessity, skin status, prophylaxis, disposition, patient/family concerns and daily goals.  I developed a detailed management plan on the basis of these assessments.   Brief exam: intubated, not awake/responsive. Pupils equal. Heart RRR. Abd soft. No LE edema.    Brief History and Medical Decision-Making: This is a 70yo M who is admitted to MICU for acute hypoxic respiratory failure and metabbolic encephalopathy. Diagnosed with COVID-19 pneumonia 12/28 and subsequently with bacterial pneumonia (Staph) on 1/18. He was extubated on 1/21 and re-intubated on 1/22 for respiratory distress and airway protection. LP negative for infectious etiology. He is requiring minimal ventilator support at this time.  MRSA is negative, discontinue IV vanc. On prolonged steroid taper: switch to prednisone to complete. Will also transition sedation to precedex to allow more wakefulness and assessment of mental status CHIEF COMPLAINT: COVID   Assessment/Plan    ASSESSMENT / PLAN: Patient is a 70 y.o. male with a history hypertension, hyperlipidemia, chronic obstructive pulmonary disease, lymphoma of the neck status post chemo radiation, presents after being found for approximately 2 days. Noted that recently diagnosed with COVID-19 pneumonia on 12/26.  On arrival, patient with altered mental status, shock, acute hypoxic respiratory failure.  Admitted to MICU.   Shock - Undifferentiated MSSA pneumonia COVID-19 pneumonia Suspected multifactorial in setting of sepsis and hypovolemia.  Differential includes sepsis given MSSA PNA, recent COVID PNA (dx 12/28, Doppler b/l UE and LE 1/18 neg), noted procal 0.81. CT thorax (1/18) showed bilateral GGO consistent w/ COVID. Possible cardiogenic, although limited echo 1/18 technically limited study. CTA (1/22) showed no diffusion defects ruling out PE/obstructive shock. CRP elevated noted.  Culture data:   - Respiratory culture (+) 10-50,000 Staph aur and Beta hem strep, many WBC, gram (+) rods and gram (+) cocci,               - Film array for atypical pathogens (-) except for COVID (+), Urine antigens (-)              - Pancultures from BAL: fungal (-) legionella (-), legionella FDA antibody (-), pneumocystis stain (-) - Blood cultures NGDT              - Repeated cultures when febrile on 01/23, NGD   Plan - Antibiotics- Zosyn, discontinued Vanc after (-) MRSA (1/24) - NE stopped 1/21 9am - C/s palliative care to continue goals of care discussion              - Connected with SW, APS transfer started   Acute Hypoxic Respiratory Failure Differential includes COVID pneumonia / sequelae vs. superimposed bacterial pneumonia (procal 0.8).  Intubated for airway protection (1/18). CT non contrast chest (1/18): bilateral diffuse ground-glass opacities  CXR (1/19): R sided. L sided consolidation, mild elevation of L hemidiaphragm  Extubated (1/21) Reintubated (1/22) airway protection for difficulty clearing secretions, poor mental status, tachypnea Plan - Prednisone taper started, Methylprednisolone 40mg BID 5 days course completed - Precedex switch (for sedation and to see if can help AMS) - Bronchoscopy at reintubation showed bilateral thin secretions              - BAL cultures showed few WBC and no org (1/24) - Titrate vent settings as tolerated - Goal O2 90-96% - Continue trend ABGs  - Lasix 40mg BID IV   Encephalopathy No prior hx cognitive dysfunction  CT head and cervical spine (1/18) unremarkable. TSH wnl. UDS neg. Intubated for airway protection (1/18) Concern for possible seizure, initially started on 2h EEG and Neuro Epilepsy recommended expand to long term due to abnormal possible focus of seizure risk in occipital lobe. Started on Vimpat. Follow up EEG negative for seizure. DDx at this time toxic metabolic vs seizure vs stroke given occipital abnormality noted on EEG vs meningitis vs uremia. Noted some RLE shaking for few sec on 1/20, contacted Neuro Epilepsy and no seizures on EEG, EEG stopped (1/21) when no seizures were seen clinically or on EEG. (1/23) HSV PCR (-). (1/24) LP (-) with 2 WBC, glucose and protein w/n/l, no blood Plan: - Neurology formally consulted. Appreciate recs.               - Keep on Vimpat until outpatient neurology follow-up (PR interval w/n/l 122) - F/u MRI brain to definitively r/o intracranial process   S aureus PNA Pos resp cx 1/18 for S aureus, also GPR Neg MRSA nares Blood cx NGTD Plan: - Abx per above for shock   COVID-19 (+) Infection Recent diagnosis COVID (+) 12/26/21 Vaccinated and boosted Plan - Out of window for Remdesivir  - (above) cont. steroids   AKI (resolved) Baseline normal renal function (1.0) Creatinine on arrival 2.91 with BUN of 124.  Etiology likely pre-renal based on BUN/Cr ratio >20, shock (1/22) BUN 62 trending down, Cr 1.07 Plan - Foley catheter in place for strict I/Os - Will trend with daily labs, trending down   Rhabdomyolysis (resolving) Trended down from 2,500 to 1,200. Patient had been found down prior to arrival.    Concern for PE (Resolved) Patient is at high risk for thrombosis given malignancy and COVID infection. CTA unable to be performed due to AKI on admission. Doppler ultrasounds all 4 extremities to rule out DVT (-) (1/18) Limited Echo (1/19): difficult to read but no signs of RV strain CTA (1/22): No diffusion abnormalities or concern for PE. Plan - heparin gtt -> heparin SQ on 1/22   Hypernatremia  Na 148 (1/20) free water deficit 2L, Na 147 (1/24)- 0.2L free water deficit Most common form in the ICU is hypervolemic hypernatremia usually due to a free water deficit from decreased fluid resus. during later hospital course due to the overload of early saline administration in the beginning.  No obvious hypernatremic medications seen, can ask pharm.  Plan - Free water flushes 200ml q4  - Trend with CMP              - If increase in Na at next CMP, increase free water flushes   Elevated LFTs (resolved) AST 140, ALT 85 (1/18), AST 39, ALT 30 (1/22) CT thorax significant for cholelithiasis Total bilirubin elevated 2.7 Likely due to shock Plan - ALT/AST improved - continue to monitor CMP   T2DM Glucose has been in high 250's on low-dose corrective (1/18) Plan - Endotool started (1/19), glucose within 180-140 - Continue to monitor glucose     Lines:  R IJ (1/18), R art line (1/18) Drains: Foley (1/18) Airway: Intubated (1/22) Pressors: None (NE stopped 1/21 9am) Diet: TF VTE Prophylaxis: Heparin SQ Code Status: Full unknown GI ppx: PPI daily ,increasing since last BM 1/21 SUBJECTIVE: Overnight: He spiked a fever around 1200 and 2000, tylenol was given and temps have been w/n/l since. The bx zosyn was increased due to the fevers but vanc was stopped due to negative MRSA. No other acute events or major concerns.   Review of Systems Unable to perform ROS: mental status change BP 109/50  | Pulse 103  | Temp 37.9 °C (100.22 °F)  | Resp 30  | Ht 1.744 m (5' 8.66")  | Wt 103 kg (227 lb 1.2 oz)  | SpO2 91%  | BMI 33.86 kg/m²  FIO2 (%): 30 % Physical Exam Vitals reviewed.  Constitutional:      Appearance: He is ill-appearing.  HENT:     Head: Normocephalic.     Mouth/Throat:     Pharynx: Oropharynx is clear. No oropharyngeal exudate.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.  Pulmonary:     Comments: intubated Abdominal:     General: Abdomen is flat.     Palpations: Abdomen is soft.  Skin:    General: Skin is warm.      Restraint type: Soft   Restraint etiology: Encephalopathy