Age: 70.0
Sex: M
Vaccine: COVID19-2
Symptoms: Blood chloride decreased, Blood creatinine normal, Blood gases, Blood gases abnormal, Blood glucose normal
Clinical narrative: COVID +10/29/22  Vaccination status - Moderna x4 + moderna bivalent BRIEF OVERVIEW: Discharge Provider:  Primary Care Provider:  Admission Date: 10/29/2022 Discharge Date: 11/1/2022    Active Hospital Problems   Diagnosis Date Noted POA ? Acute on chronic respiratory failure with hypoxia (HCC) 10/29/2022 Yes ? Acute exacerbation of chronic obstructive pulmonary disease (COPD) (HCC) 01/12/2016 Yes ? Post-COVID chronic shortness of breath 10/29/2022 Yes ? Emphysema lung (HCC) 05/11/2022 Yes ? Respiratory failure (HCC) 10/30/2022 Unknown   DETAILS OF HOSPITAL STAY: Clinical Narrative: Patient was admitted for acute on chronic hypercapnic respiratory failure and a chronic obstructive pulmonary disease exacerbation.  He was treated with corticosteroids and IV antibiotics with improvement.  He is noted to have several recent Zephyr valves placed by the Pulmonary Transplant Service.  He will follow-up there.  He was started on BiPAP on discharge and I discussed his follow-up care with his attending pulmonologist, Dr. The patient desires home discharge, is back to his baseline, is back to his baseline oxygen needs, and desires home discharge today.     Please see the following problem-list oriented Hospital Course below:   Acute exacerbation of chronic obstructive pulmonary disease (COPD) (HCC) Assessment & Plan DuoNeb every 4 hours scheduled. P.r.n. albuterol every 2 hours for wheezing or shortness of breath. Prednisone 40 mg daily. Continue Symbicort and Spiriva. Patient currently taking prophylactic azithromycin.  Continue during hospitalization. Continue Singulair. Patient has an appointment scheduled with pulmonology on November 3, 2022. He plans to keep appointment.  10/30....  Usually on 4 L nasal cannula at baseline at home  Presently on 4 L nasal cannula here but still short of breath Continue breathing treatments with DuoNebs Continue steroids, Mucinex, will add Acapella Continue Zithromax 10/31....  Patient remains on 4 L at rest but desaturates with exertion He also has a little bit of conversational dyspnea ABG yesterday showed a CO2 retention of 64.9, had ordered a BiPAP last night but patient refused This morning ABG showed a worsening CO2 retention of 67.8 with patient still hypoxic He finally agreed to use BiPAP today Will monitor vitals and ABG closely today Continue steroids, breathing treatment, Mucinex, Acapella and Zithromax 11/1 - oxygen needs back to baseline at 4 liters/minute.  Functional status back to baseline.  Discharge planning today.  He has been on prednisone frequently throughout the last month it has not been off of it for significant intervals.  He will therefore require somewhat of a taper.  He will follow-up with Dr. his Pulmonologist.  Discussed with Dr. by phone.   * Acute on chronic respiratory failure with hypoxia (HCC) Assessment & Plan Titrate oxygen to effect. Continuous pulse oximetry monitoring. Cough and deep breathe. Continue home medications. Early progressive mobility. VBG with a.m. lab draw. 10/30.....  Continue to wean oxygen Continue treatment for chronic obstructive pulmonary disease as above and monitor closely 10/31....  Continue oxygen as per protocol Patient had refused BiPAP last night but agreed to use it today Will monitor closely and follow up on repeat ABGs Patient has a history of pulmonary valve placement x6 and has a follow-up appointment a on Thursday 11/1 - the patient has been in discussion.  His pulmonary transplant service has moved his office visit out a few weeks to allow some time for recovery.  In speaking with the patient it is clear that he has had several suffer/endobronchial valves placed in the last several months.  The most recent was approximately 4 weeks prior.  Discussed his case with Dr. his Pulmonologist, on discharge regarding pulmonary follow-up, initiation of BiPAP therapy (and timing given the recent endobronchial valves) given his chronic CO2 retention and chronic respiratory acidosis.  Also discussed his corticosteroid management and follow-up in the pulmonary office. The patient also follows in the Clinic and has follow-up there as well.  His oxygen are back to baseline on discharge. Post-COVID chronic shortness of breath Assessment & Plan Prednisone 40 mg daily. No evidence of acute infiltrate on CT angiogram of thorax completed today. Patient is successfully treated with Paxlovid.  Patient originally diagnosed September 29, 2022. Only symptomatology headache and fatigue. Emergency department retested patient today, he remains positive well virus.  He is asymptomatic.  I do not believe this is an active viral infection and positivity is expected.  COVID-19 treatment precautions and respiratory isolation only necessary if according to hospital policy. 10/30.....  Not a candidate for remdesivir, Not considered a new acute infection Continue steroids for chronic obstructive pulmonary disease Continue breathing treatments 10/31....  Continue treatment as above 11/1 - Doing well. Fully vaccinated for Covid/Influenza and Pneumococcus.  Emphysema lung (HCC) Assessment & Plan 10/31....  Patient has a history of pulmonary valve placement x6 done and has appointment to follow-up on Thursday 11/1 - Zephyr Endobronchial Valve placements (endobronchial stenosis? Bronchomalacia?) and has follow-up and a scheduled appointment. He does not smoke.