Age: 81.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Stool analysis normal, Tracheal disorder
Clinical narrative: Hospitalized (9.27.21);  COVID-19 positive (9.27.21);  Fully Vaccinated PLUS booster  CHIEF COMPLAINT: Pneumonia due to COVID-19 virus HISTORY OF PRESENT ILLNESS: Patient is a 81 y.o. male with past medical history of TBI, tracheal stenosis s/p tracheostomy, BPH, cardiac arrest, celiac disease, HTN, Hyperlipidemia, GERD with PUD, CVA and DMT2. Patient presented to ED for increased O2 demands and increased tracheal secretions per home care nurse. Patient had COVID in 5/2020, was fully vaccinated and received booster vaccine, also had positive antibody testing 9/17/21. Home nurse reports for the past 72 hours he has not been himself. He has had increased oxygen needs, typically only wears oxygen PRN but has been needing 3L constantly with ongoing desaturations into 70s. She has noted increased thick yellow secretions from trach. He has chronic productive cough which she notes is worse the past 72 hours or so. She has also noted new edema in feet x1 week, increased fatigue and decreased participation in conversation.    Patient reports he feels "terrible". Notes chest discomfort. Cannot describe further. When asked if he it was chest pressure, like and elephant sitting on his chest or chest pain he says "no like an ant sitting on it, just discomfort" Denies feeling SOB. Complains of abdominal discomfort and nausea which per home care nurse has been ongoing for 3 weeks. Taking zofran at home. Had been having diarrhea too but patient reports has has not had any in a couple of days. Home nurse reports he had stool studies which were unremarkable. In ED he was initially on 5L O2 but has been weaned to 3L currently. BP elevated, remainder of VSS. Labs with Creatinine 2.03, LA 1.6, Procalcitonin 0.08. COVID positive. BCx2 drawn. CXR with bibasilar airspace disease suspicious for pneumonia. He was given Rocephin, Azithro and decadron in ED. NOTE from 9.30.21:  Plan: -continue remdesivir and decadron for treatment of COVID 19 -ASA and plavix currently on hold due to concern of bleeding near feeding tube -IR replaced feeding tube on 9/29. -follows with home Palliative care. Palliative care consulted and following. -continue to monitor H/H q12h-stable -continue home meds as appropriate:  Nebulizers per home regimen, gabapentin, Synthroid, metoprolol, inhalers, ppi, Flomax, trazodone -continue basal bolus insulin.  Monitor blood sugars closely and adjust as needed while receiving Decadron. Increase lantus and corrective insulin. Consult DGMS for assistance of management with insulin. -Doctor requesting patient to be started on pancrealipase supplements due to concerns for pancreatic insufficiency. Discussed with inpatient pharmacist, will start with pancrealipase 24 2 tabs with meals and 1 tab with snacks -monitor mentation closely. Possibly related to steroids and hospital delirium. Redirect as able -PT/OT -redirect is needed -diet:  Diabetic diet, 300mL water flushes q4h -DVT prophylaxis: if FIT negative, subq heparin -Full code Dispo: Continue current treatments for COVID 19 (remdesivir & decadron). If worsening mentation, may have to consider holding steroids. DGMS consulted for assistance with insulin and blood sugars. Continue free water flushes through feeding tube. Redirect as needed. PT/OT. Continue nebulizers treatments and other meds. Start creon for pancreatic insuffiency