Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anaemia macrocytic, Blood creatinine increased, Blood lactic acid, Bronchitis viral
Clinical narrative: COVID +(?) 12/2/22   Vaccination status - moderna x3 H&P - CHIEF COMPLAINT Cough, dyspnea ASSESSMENT Principal Problem:   Acute respiratory failure  Active Problems:   ESRD on dialysis    History of myocardial infarction   Secondary hypertension   GERD (gastroesophageal reflux disease)   S/P CABG x 3   Oropharyngeal dysphagia   Microscopic polyangiitis    Anemia   Coronary artery disease involving native coronary artery of native heart without angina pectoris   Chronic diastolic HF (heart failure)    Stenosis of left carotid artery   Controlled type 2 diabetes mellitus, without long-term current use of insulin    Acute hypoxemic respiratory failure  PLAN Acute hypoxic respiratory failure 2/2 RSV bronchitis Possible Acute COVID-19 infection Hx of COVID-19 infection 10/2022 -Presenting with rhinorrhea, cough, dyspnea since 11/30 -Requiring 1-2 L NC for intermittent desaturations at rest -Chest xray negative for infiltrates; no leukocytosis -Exam notable for wheezing and fine crackles -COVID-19 / RSV PCR positive but COVID could be residual positivity from October infection. True infectivity status will not change management since plan for steroids regardless and not remdesivir candidate due to ESRD status. Plan -Given IV Solumedrol in ED. Due to ongoing wheezing, continue with Prednisone 40 mg x 5 days for viral bronchitis. -Will not start azithro/doxy for antiinflammatory given questionable COPD diagnosis -Scheduled albuterol nebs q 6 hours -Ambulatory pulse ox test ordered -Guafinesen, antitussives, incentive spirometry -Continuous oximetry, goal O2 sats > 92%  Questionable COPD diagnosis -Long-term diagnosis in chart.  -However, PFTs 06/13/2018 w/ normal FEV1/FVC (Positive bronchodilator response.  Normal TLC moderate DLCO impairment).  -Previously seen by pulm in context of DAH workup who reviewed PFTs but never labeled as COPD -Never smoked tobacco Plan -Recommend repeating PFTs outpatient when recovered -Recommend stopping advair diskus since she is only using "as needed" and could increase long-term infection susceptibility  -Continuing steroids and albuterol for viral bronchitis   Acute on chronic macrocytic anemia  -Hgb 8.9 on admission, trending 11.7 on 7/2022 w/ fluctuation 9-11 range previously -Denies symptoms of GI bleeding -EGD 4/2022 unremarkable -Receives Venofer with dialysis -Already on folate and B complex vitamin Plan -Will recheck iron studies -Trend with daily CBC  H/o microscopic polyangitis presenting with diffuse alveolar hemorrhage (2019) -Treated in 2019 with high dose steroids and rituxin -Denies recent hemoptysis  Prior history of oropharyngeal dysphagia Diagnosed during hospitalization 2019 for DAH and was on dysphagia soft and nectar thick liquids diet -No longer follows dysphagia diet, denies any recent dysphagia symptoms and passed bedside swallow Plan -SLP reconsulted for evaluation -Dysphagia soft diet w/ thin liquids in interim  Hypertension Hyperlipidemia BP 190s/70s in ED likely due to missed antihypertensives and coughing -Continue Norvasc, losartan, metoprolol and statin  HFpEF CAD s/p CABG x 3 in 2017 Hx of STEMI Chronic LBBB Echo 07/2022:  Moderate LVH, EF 55%, grade 1 diastolic dysfunction, no significant valve disease NT pro BNP elevated in setting of ESRD but appears euvolemic and CXRAY without edema -Continue ASA 325 mg daily (hx CVA) -Daily weights / Strict I/O  Hx CVA  -chronic lacunar infarcts on prior CT head -continue ASA 325 mg daily  ESRD on HD (T/TH/Sat) -Last HD on 12/1 -Nephrology consulted -daily weight, strict I&O, avoid nephrotoxins  Non-insulin-dependent type 2 diabetes Last A1 c 5.5 in 07/2022 Not on oral medications at home -24 hour corrective with initiation steroid  GERD -Continue PPI  RLS -continue ropinirole  DVT ppx:  Heparin TID due to COVID diagnosis if a.m. hemoglobin remains stable Diet:  Renal Code status: Full Code per discussion with patient on admission   HISTORY OF PRESENT ILLNESS Patient is a 77 y.o. female with past medical history significant for microscopic polyangiitis (with history diffuse alveolar hemorrhage 2019, s/p steroids and rituxin), ESRD on HD, CAD with STEMI s/p CABG (2017), chronic diastolic heart failure, CVA, hypertension, hyperlipidemia, non-insulin-dependent type 2 diabetes, chronic anemia and GERD who presented to the emergency department from her PCP office due to hypoxia.  Since 11/30, patient developed significant, nonproductive cough, rhinorrhea, dyspnea and intermittent chills.  She completed her typical dialysis run on 12/1 (Thursday) but reportedly needed intermittent oxygen at that time to maintain saturations. She feels mildly dyspneic at rest but more so with ambulation. Persistent cough is most bothersome. Appetite decreased. No sick contacts, hemoptysis, fevers, loss of taste/smell, sore throat, chest pain, nausea, vomitting, abdominal pain or leg swelling.  Her albuterol inhaler has been providing relief but she states that she only uses her Advair "as needed". Diagnosed outpatient with COVID-19 (PCR positive) sometime during October with primary symptoms being cough but she does not recall if she received any treatment or any other related symptoms.   Of note, she carries a diagnosis of COPD and has longterm Advair (which she has only been using as needed) and albuterol INH Rx but PFT in 2018 showed no obstruction by FEV1/FVC (Positive bronchodilator response.  Normal TLC moderate DLCO impairment). Has been seen by pulm both inpatient and outpatient during treatment/sequelae of DAH and never been labeled with COPD. Never smoked tobacco. Not on oxygen at baseline.   In the emergency department, vital signs were notable for tachypnea with respirations trending mid 20s and hypertension with blood pressure 194/71.  She intermittently desaturated to 88% at rest which improved to O2 98% on 2 L nasal cannula.  Labs notable for creatinine 4.71 (in setting of ESRD), NT proBNP 47920, lactic 1.5, no leukocytosis, hemoglobin 8.9 with MCV 101. COVID 19 and RSV PCR positive.  Chest x-ray without consolidation or opacifications.  I independently reviewed EKG which showed normal sinus rhythm with a chronic left bundle branch block which is grossly unchanged from EKG compared to 07/2022.  QTC is 466 when corrected for LBBB.  She was given Solu-Medrol IV 80 mg and albuterol inhaler.  Transfer to Hospital due to lack of dialysis capability at Hospital.  Admitted for acute hypoxic respiratory insufficiency secondary to RSV and possible COVID 19 infection. 12/6/22 General Med Hospital progress note:  ASSESSMENT / PLAN:  Acute hypoxic respiratory failure  Secondary to RSV bronchitis Hx of COVID-19 infection 10/2022 Prednisone 40 mg x 5 days for viral bronchitis, end date 12/7 -Scheduled albuterol nebs q 6 hours -Ambulatory pulse ox test ordered -Guafinesen, antitussives, incentive spirometry -Continuous oximetry, goal O2 sats > 92%  Questionable COPD diagnosis -Long-term diagnosis in chart.  -However, PFTs 06/13/2018 w/ normal FEV1/FVC (Positive bronchodilator response.  Normal TLC moderate DLCO impairment).  -Previously seen by pulm in context of DAH workup who reviewed PFTs but never labeled as COPD, Never smoked tobacco -Recommend repeating PFTs outpatient when recovered -Recommend stopping advair diskus since she is only using "as needed" and could increase long-term infection susceptibility  -Continuing steroids and albuterol for viral bronchitis   Acute on chronic macrocytic anemia  Iron deficiency anemia -hemoglobin stabilized around 9-10 during this hospital stay -Already on folate and B complex vitamin  H/o microscopic polyangitis presenting with diffuse alveolar hemorrhage (2019) -Treated in 2019 with high dose steroids and rituxin -Denies recent hemoptysis  Prior history of oropharyngeal dysphagia -SLP consulted for evaluation Dysphagia soft diet w/ thin liquids in interim  Hypertension Hyperlipidemia -Continue Norvasc, losartan, metoprolol and statin  HFpEF CAD s/p CABG x 3 in 2017 Hx of STEMI Chronic LBBB Echo 07/2022:  Moderate LVH, EF 55%, grade 1 diastolic dysfunction, no significant valve disease NT pro BNP elevated in setting of ESRD but appears euvolemic and CXRAY without edema -Continue ASA 325 mg daily (hx CVA) -Daily weights / Strict I/O  Hx CVA  -chronic lacunar infarcts on prior CT head -continue ASA 325 mg daily  ESRD on HD (T/TH/Sat) -Last HD on 12/1 -Nephrology consulted -daily weight, strict I&O, avoid nephrotoxins  Non-insulin-dependent type 2 diabetes Last A1 c 5.5 in 07/2022 Placed on 24 hour insulin corrective and allowed to fall off  GERD -Continue PPI  RLS -continue ropinirole  DVT ppx:  Heparin 5000 TID