Age: 58.0
Sex: M
Vaccine: COVID19
Symptoms: Leukocytosis, Malnutrition, Mechanical ventilation, Mechanical ventilation complication, Patient restraint
Clinical narrative: PULMONARY PROGRESS NOTE 2/6/2022 Unable to participate   Interim: Supine, on vent. O2 needs improving: FiO2 35%, PEEP 5 Dyssynchronous with vent despite prns, and thus NMB dose given WBC up significantly, Afebrile, CRP stable Ongoing low dose pressors     Today: lighten sedation and see how does with pressure support to get idea of weanability: update 2/6/2022 2:16 PM: he did poorly O:  BP 96/62  | Pulse 94  | Temp 97.8 °F (36.6 °C)  | Resp (!) 28  | Ht 5' 5.98" (1.676 m)  | Wt 60.1 kg (132 lb 7.9 oz)  | SpO2 94%  | BMI 21.40 kg/m²  Temp (24hrs), Avg:98.4 °F (36.9 °C), Min:97.8 °F (36.6 °C), Max:99.3 °F (37.4 °C)     Intake/Output Summary (Last 24 hours) at 2/6/2022 0845 Last data filed at 2/6/2022 0600 Gross per 24 hour Intake 3193.6 ml Output 2210 ml Net 983.6 ml   Drips: Norepi (weaned off overnight), Versed, Dilaudid   Patient on ventilator: Settings: Mode: APVcmv, Set Rate: 28 breaths per minute, Inspiratory Pressure: (not recorded), PEEP: 8 cmH2O, FiO2: (S) 50 % PROBLEM LIST: Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Acute respiratory failure with hypoxia   SUMMARY: 58 yo man with reported h/o TB who got double vaccinated last Nov admitted with worsening SOB x few weeks, now admitted with hypoxic resp failure; COVID + on 1/13.     ASSESSMENT AND PLAN Pulmonary: Acute hypoxic resp failure due to COVID pneumonitis. Failed BiPAP. Was intubated 2/1, begun on proning and FS Flolan. FiO2/PEEP requirement improving. Weaning flolan.    Claims h/o pulmonary TB; need to get more details - unable to corroborate as yet on Care Everywhere. Had essentially nl CXR 10/31/21 (see report above).   Cardiac/Hemodynamics:  Persistent tachycardia - resolved since intubation.  HTN - resumed his PTA Lisinopril/HCTZ; now both DC with lower BP's on vent. Hypotension - since started on deep sedation with intubation - Cont Levophed   Renal/Fluids/Electrolytes: Nl renal fcn, lytes. Has been on furosemide 20 mg q 8 hrs since 2/1; back off to daily as of 2/3. Is on K/Mg replacement protocols.    ID/Sepsis/Severe Sepsis: COVID pneumonitis (despite being double vaccinated in Nov 2021). CRP has been decreasing steadily; down to 3.6 as of 2/4 (down from peak of 18 on 1/31).  Procalcitonin sl elevated (0.24). Was out of the window for toci/baricitinib as COVID + as of 15 days ago.  CRP coming down; continue Dexamethasone 6 mg q 12 hrs.  On 1/28 PM was started on empiric ceftriaxone (thru 2/3) and azithro (completed 5 day course 2/1) to cover for possible CAP.  Also has h/o TB - not seeing much to corroborate any details.   GI: no acute issues   Heme/coags:  Was switched to full dose A/C with enoxaparin on 1/30 with rising D-Dimer; coming down 11.4 on 1/31--- >-- >3.7 on 2/4.   Moderate leukocytosis; WBC sl elevated. Mild anemia  Plts wnl   Neuro: Intact; no acute issues. Has prn Nimbex but has not needed at all.   Nutrition: modestly malnourished:  o Was started on TF's (unable to get FT post pyloric) 2/3 but suggestion of regurgitation. On 2/4 FT was changed to small bore gastric (rather than failed PPFT). o 35 lb weight loss over ~2 months PTA - unknown etiology.   Endocrine: h/o prediabetes mellitus (HbA1C still pending) watch for hyperglycemia on dexamethasone. BS well-controlled.   Sedation/Analgesia: Deep sedation: Versed and Dilaudid gtts (has not needed any NMB boluses). RASS goal decreased to 0 to -2.   Restraints: Now needed; renewed.   Lines/Site: LUE PICC line placed 2/1   Code Status: Full code   Prophylaxis: Head of bed elevated DVT Prophylaxis: Lovenox (full dose) 80 mg q 12 hrs; decreased to 40 mg q 12 hrs as of 2/4 PM Glucose control - SQ insulin Ulcer Prophylaxis: H-2 Blocker