Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Hypoxia, Iliac artery stenosis, Intensive care, Laboratory test normal, Lung disorder
Clinical narrative: Hospitalized (1.20.22 - still admitted currently); COVID-19 positive (1.20.22); Fully vaccinated -J&J x1 1/31/22 Medical Critical Care progress note:  ADMISSION DATE: 1/20/2022 PRESENTING PROBLEM:Respiratory failure Acute respiratory failure with hypoxia COVID-19   Active Hospital Problems   Diagnosis Date Noted POA ? Co-morbid condition 01/30/2022 Unknown ? Anxiety 01/28/2022 Unknown ? Goals of care, counseling/discussion 01/28/2022 Unknown ? Anemia 01/25/2022 Unknown ? Abdominal aortic aneurysm (AAA) 3.0 cm to 5.5 cm in diameter in male  01/25/2022 Unknown ? Pneumonia of left lower lobe due to Pseudomonas species 01/24/2022 Unknown ? Peripheral vascular disease 01/24/2022 Unknown ? Acute respiratory failure with hypoxia 01/20/2022 Unknown ? Shock 01/20/2022 Unknown ? COVID-19 01/20/2022 Unknown ? Acute pulmonary embolism without acute cor pulmonale 01/20/2022 Unknown ? Pericardial effusion 01/20/2022 Unknown ? OSA (obstructive sleep apnea) 03/09/2016 Yes ? COPD (chronic obstructive pulmonary disease) 01/20/2011 Yes ? HTN (hypertension) 01/20/2011 Yes ? DM (diabetes mellitus) 01/20/2011 Yes ? Dyslipidemia 01/20/2011 Yes ? Seizure   REASON FOR TRANSFER: Clinical improvement, no longer requiring ICU level care DATE OF TRANSFER: 1/31/2022 TRANSFER DESTINATION: w/ tele   BRIEF SUMMARY OF CARE: 68 year old male history of seizure disorder, COPD (2L O2 dependent), CAD, DM2, HTN, HPL, PAD presented via EMS to the ED 1/20 with altered mental status. He was found down 1/20 next to his bed by EMS laying on his oxygen tubing and was hypoxic at 60%. He was placed on a NRB. He was disoriented and incomprehensible. In the ED he was found to have respiratory acidosis thus he was intubated. Shortly after intubation he had a brady PEA cardiac arrest (2 rounds CPR with 1 epi given). CXR noted no PTX. COVID PCR +. CTA revealed moderate segmental and subsegmental PE and significant left lower lobe pneumonia that has grown Pseudomonas, on Zosyn. Head CT was negative. He was on escalating vasopressors thus was transferred to the MICU for further monitoring. Failed trial extubation and ultimately re-intubated on 1/27 due to hypoxia and agitation. Vent settings stable and he passed SBT 1/30 and was extubated to BiPAP.  Palliative continues to follow, patient plans to sign onto Hospice.  Transferred to the hospitalist service as arrangements are made for discharge home per the patient's wishes.  Spke with doctor who accepted the patient for transfer. CONSULTS: IP CONSULT TO SPIRITUAL CARE IP CONSULT TO NUTRITION IP CONSULT TO NUTRITION IP CONSULT TO NUTRITION SUPPORT (PHYSICIAN CONSULT) IP CONSULT TO SOCIAL WORK IP CONSULT TO PSYCHIATRY IP CONSULT TO PALLIATIVE CARE   PROCEDURES PERFORMED:   -1/20: Intubation   /  1/20: R femoral arterial line    /  1/20: R femoral CVC    / 1/20: EEG 1/21: Bronchoscopy   /  1/21: Corpak 1/22: Left radial arterial line    /  1/22: Left IJ CVC 1/27: Intubation   RECOMMENDATIONS AT TRANSFER:   Acute on chronic hypoxemic respiratory failure Has baseline emphysema that is oxygen dependent.  ETT 1/20-1/25; 1/27-1/30 Bronchoscopy culture from 1/21 +Pseudomonas resulted as pansensitive, Sedation: Fentanyl, Preceded Diuresis: Lasix 20mg BID 1/30: Plan for one way extubation to BiPAP while on precedex. Patient in agreement as well as family. All with the understanding that he may not tolerate extubation in which case they would proceed with comfort care.  Palliative care at bedside during conversation - will continue to follow. 1/31: Stable off BiPAP, will use for naps / night. Precedex weaned off   Moderate Segmental/subsegmental PE Therapeutic Lovenox  -COVID pneumonia  - Remdesivir course 1/20-1/24 Solumedrol 1/20-1/22 40mg  BID, 1/23-1/25 30mg BID, 1/26-1/29 20mg BID, 1/30- 20mg QD -Pseudomonas pneumonia   -+ culture from BAL 1/21 Abx below  -Hypotension, resolved In-hospital arrest on day of admission: CTA +PE, ECHO 1/20 showed EF of 55%, small pericardial effusion, normal RV function without evidence of strain.  Head CT with no acute findings. S/p NE for MAP goal >/=65mmHg -CAD -HPL -Peripheral arterial disease -H/o HTN Infrarenal abdominal aortic aneurysm, 3.6cm CT A/P revealed high grade stenosis left common iliac artery.  Holding home clopidogrel currently as it is unclear if he will end up needing a tracheostomy.  Consider value of adding clopidogrel daily in the context of tracheostomy requirement, while continuing heparin infusion. ASA, statin Catapres restarted 1/31 Amlodipine held -Chronic pancreatitis CT A/P chronic calcification causing obstructive dilation of pancreatic duct Appears stable, not trending pancreatic labs. -Anemia -Borderline Hgb - no indication for emergent transfusion at this time  -Altered mental status, resolved   -Seizure history   -Head CT with no acute findings EEG 1/20  with severe diffuse slowing without seizure Continue home phenytoin.  Phenytoin level low at 1.2 on 1/24.  -Agitation/anxiety Following extubation was anxious, hyperventilating, and agitated which contributed to reintubation Seroquel 25 mg bid Clonazepam 0.25 mg bid -Psych consulted on 1/28 -BPH   - Hold proscar Foley -Diabetes mellitus type 2 hgb a1c 7.3 stress hyperglycemia, basal bolus insulin in context of tube feeds -DVT prophylaxis Therapeutic Lovenox -GI prophylaxis Protonix   Code status: DNR/DNI   Lines:  Right femoral CVC 1/20-22 / Right femoral arterial line 1/20-22 / Left IJ CVC 1/22-1/31 / L radial A line 1/22-1/31   Drains:  Corpak 1/21 / Foley   Airways:  ETT 1/20-1/25; 1/27-1/30   Antibiotics: Zosyn 1/20, 1/22-1/24 / Ceftazidime 1/24-2/2 / Ceftriaxone 1/20-1/22 / Azithro 1/20-1/22 / Vanco 1/20-1/22   CONDITION AT TRANSFER: stable