Age: 79.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Acute respiratory failure, Akinesia, Blood culture negative, Blood lactic acid, COVID-19
Clinical narrative: Hospitalized (9.11.21 - present;  febrile neutropenia);  COVID-19 positive (9.11.21);  Fully Vaccinated  SUBJECTIVE:   This is a 79 y.o. patient with a past medical history significant for cardiomyopathy, hypertension, PVD, CKD, past CVA/SAH, CLL on chemo, recent AKA presenting to the emergency department via EMS from bed for evaluation of fevers, neutropenia, concern for sepsis. Patient found to be COVID positive with questionable lower lobe infiltrate. Given neutropenia, she was started on cefepime and will be admitted for further work-up and monitoring.   Upon assessment, patient resting in bed with daughter at bedside.  Patient and daughter provided the history.  Patient reports she was in last week for left foot/LE amputation related to chronic non-healing wound.  She then went to another facility. She denies any sick contacts, states she is fully vaccinated and has been very careful.  Denies SOB, no cough.  Denies any new rash, pain with urination (though does report frequency).  No issues at amputation site.  Daughter reports wound on her bottom r/t being in bed and diarrhea - states she has been using skinguard to help.  Patient also with recent MI - about 4 weeks ago.  Has been taking her meds.  Denies any CP, palps, swelling in legs.  Labs and plan of care reviewed.  All questions answered.  DISPO: -continue cefepime, monitor infectious w/u -appreciate ID input -monitor renal fxn, may need to hold entresto/lasix if worsening -please ask to sign blood consent 9/12, declined 9/11 with being tired/overwhelmed  ASSESSMENT / PLAN:     Febrile Neutropenia -Temp 100.4 in ED, other VSS -lactic 1.6 -- > 0.9 -CXR 9/11 vascular congestion, questionable lower lobe infiltrate on lateral view -COVID positive -recent Cdiff negative on 9/2 -UA small leuks, negative nitrites; UC pending -periph BC x2 pending -Blood cx on 8/27 admit +staph hominis but determined contaminant, was on Zosyn -s/p cefepime 2G in ED, will continue Q12h -will consult ID   COVID Infection -Positive PCR on 9/11, likely hospital/facility acquired -CXR 9/11 questionable LL infiltrate -s/p dex 6mg on 9/11 -ID consulted, appreciate input -currently on room air  Progress Note from 9.21.21: CHIEF COMPLAINT: Febrile neutropenia  COVID-19  ASSESSMENT / PLAN: Acute hypoxic respiratory failure  -Multifactorial in setting of HFrEF, recent COVID, pleural effusion, interlobular fluid and b/l patchy airspace disease -sputum culture pending  -CXR 9/15 patchy perihilar consolidations pulm edema vs infecction  -CXR 9/20 bilateral pneumonia vs pulmonary edema              - ECHO 9/16 with EF 56% inferior septal wall is akinetic, right ventricle is mildly dilated and function is mildly decreased -MRSA positive  -Pulm now signed off-- rec diuresis, abx, dex -Cardiology now signed off- discontinued Entresto, continue daily IV lasix               -ID following -s/p vanco (9 days), and cefepime/ceftazidime (9 days total). Per ID monitor off antibx for now  -continue lasix 40mg BID for now  -On hi-flow- wean as able. No home O2 at baseline  COVID Infection -Positive PCR on 9/11, likely hospital/facility acquired -Asymptomatic until 9/14/21 - now req O2 -CXR 9/11 questionable LL infiltrate -CXR 9/20 pulm edema vs pnumonia -Cont dex 6mg daily x10 days (9/15-9/25) -S/p Regeneron 9/13 per ID -ID does not feel any benefit from remdesivir -Wean off O2 as able Febrile Neutropenia - resolved -Blood cx on 8/27 admit +staph hominis but determined contaminant, was on Zosyn -Most recent fever:  9/15 PM -CXR 9/11 vascular congestion, questionable lower lobe infiltrate on lateral view -COVID positive -MRSA screen positive -C diff negative on 9/2 -UA small leuks, negative nitrites; UrCx neg -CMV blood PCR neg -BCx remain NGTD  -CT head 9/13 with pansinusitits - asymptomatic -DC'd cefepime d/t encephalopathy -s/p ceftazidime/vanco-- monitor off per ID