Age: 60.0
Sex: M
Vaccine: COVID19
Symptoms: Pulmonary mass, Respiratory failure, SARS-CoV-2 test positive, Sepsis, Superinfection
Clinical narrative: Patient is a 62 y.o. male patient of, CNP with history of unusual pulmonary fibrosis complicated by chronic hypoxia (2LC at baseline), pulmonary nodules, ascending aortic ectasia, psoriasis, DDD, BPH, GERD, and polycythemia who presented to Hospital with profound SOB, and found to be hypoxic on presentation and subsequently diagnosed with COVID-19 PNA .   Sepsis, resolved Acute on Chronic Hypoxic Respiratory Failure, improving COVID-19 PNA Superimposed Pneumococcal pneumonia, present on admission Mediastinal and RIGHT hilar lymphadenopathy, reactive suspected Scattered pulmonary nodules measuring up to 1.1 cm LEFT lower lobe Unusual interstitial pulmonary fibrosis Prolonged corticosteroid use Follows with Dr. for pulmonary fibrosis of unknown etiology.  CT high resolution 6/7/23 demonstrating noncalcified nodule in LEFT lower lobe, honeycombing with traction bronchiectasis. Has had multiple steroid tapers, and has remained on steroids for approximately 3.5 weeks, and continues on taper.  On presentation the patient met SIRS criteria (RR, WBC elevation) and suspected source of infection of viral COVID-19 PNA with suspected concomitant superimposed bacterial PNA. Recorded hypoxia of 70% on 2LNC (patient's baseline). Held aggressive fluid resuscitation given normal BP, and increasing O2 requirements with COVID-19+.   D-dimer elevated, which is not unusual for COVID-19 patient. CTA chest obtained that did not demonstrate evidence on pulmonary emboli. Prolonged courses of steroids can place patient at risk of opportunistic infections, however this is typically seen in patients extending over 3 months of therapy; which is not the case in this patient. Start decadron 10mg x 10 days. Final 5 days of therapy called into patient's pharmacy. Patient finished course of Remdesivir.  Pulmonary Hygiene: ISS, Flutter, Mucinex, Deep breathing exercises to be continued after discharge. Education provided to patient by physician. Follow-up 3 months recommended to evaluate for resolution of lymphadenopathy and nodules Pulmonology consulted, appreciate recommendations. Discussed plan of care, face 2 face with Dr.   Patient was able to saturate at 87% on 4 Liter NC when walking, and maintain >6 Liters at >90%. The patient was discharged with instruction to continue on baseline 2Liters at rest, and increase to 4Liters for minimal exertion and 6Liters for moderate exertion. The patient does have O2 and concentrators that increase to 15 liters if needed. Told the patient that if he is using more oxygen then discussed or if he worsens he needs to return to hospital. He is agreeable to that. Discussed risks and benefits of discharge with the patient.  The patient will follow-up in 7-10 days to his PCP. He has a follow-up appt scheduled with Dr. The patient will be continued on decadron, and after 5 days can resume taper. If he worsens on taper he is to call Dr. to discuss and possibly resume on steroid regimen.   The patient should continue PPI and prescribed Carafate for him to take for 14 days while using steroids. The patient was evaluated by Case Management, and the patient decline HHC or PT/OT evaluation at this time. The patient has 24 hour need for baseline oxygen with progressive pulmonary fibrosis. The patient has been given letter for work, and is not to return until cleared by physician. The patient may qualify for disability and this should be discussed with his PCP.    Ectasia of ascending thoracic aorta (3.9cm) Follow up around 5/10/24 recommended, to monitor for changes Asymptomatic   Psoriasis Improved while on steroid therapies Unsure whether RIGHT Total knee replacement was caused from psoriatic arthritis, or osteoarthritis. No joint/hands changes noted on examination   Asymptomatic mild hyponatremia Suspect that mild 133Na level is a result of poor oral intake Urine Osm, Serum Osm, Urine Na levels ordered   RIGHT clavicular dense swelling, unknown etiology Disc Degenerative Disease CT scan of chest has not mentioned any change in the surround area, this should continue to be monitored and can be addressed in outpatient setting.  Chronic pain syndrome Continue Norco   BPH with obstructive symptoms Erectile dysfunction Patient taking cialis 5mg, however is not currently on BPH medications Continue to monitor during hospitalizations, can start Flomax if patient has bothersome urinary symptoms.    GERD Despite history patient is not taking PPI in the outpatient setting. The patient does receive ASA81mg for history of polycythemia secondary to chronic hypoxia, in addition the patient will be receiving Decadron during this admission. Start Protonix for ulcer prevention. Patient concerned given lack of effect on GERD while taking steroids. Will start Carafate during his hospitalization, as he repeats improved symptoms.    Polycythemia due to chronic hypoxia Patient has history of elevated Hgb, however this is normal on presentation Follows with Oncology, and should be continued on ASA81mg daily.