Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anticoagulant therapy, Blood creatinine increased, Blood lactic acid increased, COVID-19
Clinical narrative: Discharge Provider: MD Primary Care Provider:  DNP, A-GNP Admission Date: 12/5/2022 Discharge Date: Dec 5, 2022 PRESENTING PROBLEM: Hypoxia  Community acquired bacterial pneumonia  Severe sepsis (HCC)  Elevated lactic acid level  Pneumonia of right lung due to infectious organism, unspecified part of lung  Leukocytosis, unspecified type    HOSPITAL COURSE: Patient is a 84 y.o. male who presented today with 3 days of worsening dyspnea and cough.  He was severely hypoxic when EMS found him at home he was given 10 L of supplemental oxygen nebulizer treatments and steroids EN route to the emergency department on arrival at the emergency department he was breathing better but still requiring 10 L. Aggressive nebulizer therapy in the emergency department and supportive care allow them to reduce his oxygen to 2 L and still maintain sats in the 90s.  Workup demonstrated a pneumonia picture with a large right pleural effusion elevated white count elevated procalcitonin and lactic acidosis.  He was diagnosed with severe sepsis due to pneumonia and the hospitalist service was contacted for admission.  He had been started on Rocephin and azithromycin which was continued.  He was also found to be COVID-19 positive remdesivir therapy was ordered as well as Decadron.   Interventional Radiology was consulted for right thoracentesis. He has AFib on Eliquis so we are holding the Eliquis until after his thoracentesis. Unfortunately, Interventional Radiology was unable to complete the thoracentesis until Wednesday, due to the anticoagulation.  Lovenox was ordered to the unit.   Throughout the evening shift, the patient had increasing supplemental oxygen requirements.  A repeat CXR was performed, which showed much worsening right sided pleural effusion to the point where the right lung was collapsed. Patient was placed on BiPAP for greater oxygen support. Dr. from the hospital was contacted, who agreed to accept the patient for higher level of care.  Patient will be transferred by EMS to the Hospital.  Discharge Provider:  MD Primary Care Provider: A-GNP, DNP Admission Date: 12/6/2022 Discharge Date: 12/12/22 COVID positive date: 12/5/2022 PRESENTING PROBLEM: Acute respiratory failure with hypoxia (HCC)    HOSPITAL COURSE: 84 y.o. male with a past medical history of chronic obstructive pulmonary disease, atrial fibrillation on Eliquis, hyperlipidemia, tobacco use who presents with acute hypoxic and hypercapnic respiratory failure, very large right pleural effusion, developing lung abscess with sepsis, and COVID-19 infection.  Patient reports that he has been feeling short of breath for the past several days and denies any other associated symptoms.    He presented to an outside emergency department for further evaluation where he was found to require up to 10 L of oxygen and received steroids by EMS.  He was given to DuoNebs in the emergency department with improvement of his oxygen requirements to 2 L.  Other vitals notable for tachycardia, tachypnea, hypoxia to 74%, and was transiently hypotensive.  Imaging revealed a very large right-sided pleural effusion with near complete collapse of the right lung, right posterior lobe irregular area concerning for developing parenchymal abscess, consolidative focus in the left lower lobe concerning for atelectasis or pneumonia.  Labs revealed creatinine 1.25, procalcitonin 0.26, lactic acid 3.2, WBC 29.5, positive COVID-19.   Patient was admitted to the Hospital.  Initially required BiPAP support for hypoxia.  Patient had successful image guided right-sided pleural drain placement by Interventional Radiology.  Fluid analysis revealed consistency with empyema.  Patient's respiratory status significantly improved with IV antibiotics and drainage.  Patient was weaned off of BiPAP support and off nasal cannula.      Patient was treated with IV Unasyn and transition to Augmentin to complete a further 4 week course.  Will need follow-up imaging post discharge.  IR to schedule for outpatient follow-up for chest tube removal and further imaging.   Home health care arranged for continued outpatient monitoring/indication with chest tube, nutrition, ongoing antibiotic therapy for empyema.  Patient getting discharged with chest tube supplies for daily care.