Age: 77.0
Sex: M
Vaccine: COVID19
Symptoms: Metabolic function test, Mitral valve incompetence, Oxygen saturation decreased, Pleural effusion, Pneumonia
Clinical narrative: Acute on chronic hypoxic respiratory failure Covid pneumonia Small left pleural effusion  COPD Wears 1L NC at baseline, desat to the 50s at facility, requiring HFNC 95% FiO2  Covid positive here 11/9, vaccinated with Moderna x2 in the spring, Covid+ 11/2 at facility  Decadron 6 mg daily (started on 11/2 at facility) CXR with cardiomegaly, small left pleural effusion, bilateral pulmonary infiltrates predominating in left mid and lower lung, can be seen with COVID-19 pneumonia, pulmonary edema not excluded Check and trend d-dimer and CRP, initial Cr 1.5 (AKI), consider VQ to evaluate for PE, unable to obtain CTA due to AKI  S/p albuterol and duoneb, Continue home breathing treatments Scheduled and prn levalbuterol  Encourage proning Prn mucinex (productive cough), check sputum culture    AKI CXR - pulmonary edema not excluded Hold diuretics for now Diet ordered, repeat renal function in am  Denies N/V/D   CAD s/p CABG in 2011  HLD EF 73%, Mild aortic stenosis, trace MR  Not on aspirin due to bleeding in the past per chart review Continue statin   Tobacco use  Previously smoking 1/2 ppd  No cigarettes last 10 days    NASH cirrhosis  Hold spironolactone and lasix for AKI Continue cipro for ppx    Depression Continue home Cymbalta and Wellbutrin   Hypertension Hold diuretics for AKI, does not appear to be on any other anti-hypertensives at this time    DM2 insulin-dependent with hyperglycemia Continue lantus 40 units BID + high dose corrective insulin  a1c 8%   Back pain S/p spinal fusion on 09/28 with Doctor, has been at SNF for rehab  Gabapentin - renally dose  Low dose prn oxy for severe pain - caution with respiratory failure    Depression Continue home Cymbalta and Wellbutrin   Insomnia Continue trazodone nightly   GERD Continue PPI   VTE prophylaxis Lovenox, monitor closely for any signs of bleeding    Code status DNR/DNI per discussion with patient      HISTORY OF PRESENT ILLNESS: Patient is a 77 y.o. male history of COPD with chronic hypoxic respiratory failure on 1 L nasal cannula at baseline, NASH cirrhosis, tobacco abuse, depression, hypertension, type 2 diabetes mellitus insulin dependent, insomnia, GERD, coronary artery disease s/p CABG in 2011 presents with chief complaint shortness of breath. He presents from rehab facility where he has been for PT/OT after a recent back surgery in September. Pt endorses SOB, cough productive of sputum, and decreased oxygen saturation. Pt states he has felt unwell for 4 days. I spoke on the phone with a nurse at his facility who states his oxygen saturation dropped as low as 50% at one point and otherwise had been in the 80s occasionally. He was Covid positive on 11/2 and started on decadron daily at that time. His oxygen had been increased as high as 5L at the facility. Pt denies f/c/s. He tells me he has been crying a lot and feels very emotional. Denies chest pain, abdominal pain, N/V, dysuria, diarrhea. States he has had a good appetite and denies swallowing difficulty. Denies feeling wheezy. Denies orthopnea.    Pt arrives to ER tachycardic, tachypnea, 71% on room air, placed on HFNC 55L O2 95% FiO2. vPh 7.44. glucose 258. CXR with cardiomegaly, small left pleural effusion, bilateral pulmonary infiltrates predominating in left mid and lower lung, can be seen with COVID-19 pneumonia, pulmonary edema not excluded. Received albuterol and duoneb treatments. Admit to INPT for acute on chronic hypoxic respiratory failure in the setting of Covid pneumonia. ER also ordered 6 mg decadron. CMP then results with potassium of 6.3, and AKI with Cr 1.5 (0.7), hemolysis noted so will repeat. Repeat BMP shows improved potassium down to 5.4. calcium gluconate was ordered by ER staff as well as lokelma. A fluid bolus was ordered by ER staff but this is discontinued as there is concern some pulmonary edema could be worsening his respiratory status.