Age: 46.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anion gap, Basophil percentage decreased, Bladder catheterisation, Blood chloride decreased
Clinical narrative: 46yo male with h/o HLD, DM2, recent admission 9/8-9/13 for L foot abscess c/b osteomyelitis now s/p L BKA (9/11), found 9/13 to be COVID+, who presented with SOB, cough, fever and was admitted 9/19 for AHRF requiring HFNC 2/2 COVID 19 vs secondary PNA. Afebrile on admission, no leukocytosis, started on covid treatment (steroids, Remdesivir, Toci in ICU) and empiric abx (Vanc, Cefepime), but with worsening respiratory status requiring HFNC 50L/80% FiO2. Received Decadron 9/19, Solumedrol 125 q6 x4 days, Remdesivir x5 days, Toci x2 in ICU. CT chest showed moderate b/l effusions (exudative - gram stain/KOH neg for organisms), had b/l chest tube placement with drainage. Now s/p b/l chest tube removal 9/24. MRSA swabs neg, Vanc dc'ed (9/20-9/22). BCx NGTD. Pt weaned down to NC, transferred to floor. Completed Cefipime course (9/20-9/26). Weaned steroids from Solumedrol 125IV BID to 60IV BID to Prednisone 50mg with 10mg taper daily - pt currently on Prednisone 40mg. Insulin regimen adjusted accordingly to control sugars, now decreasing regimen given steroid taper. Pt also noted to be very anasarcic on presentation, diffuse b/l edema to scrotum and abdomen. BNP not elevated, lower c/f HF as etiology (EF 9/20 , thought to be more 2/2 poor nutrition/hypoalbuminemia. Received albumin while in ICU, diuresed aggressively with marked improvement in edema. Will discharge on 20mg PO Lasix. Foley placed d/t urinary retention 2/2 scrotal edema while in ICU, removed while on floor now with condom cath in place voiding well. Pt cleared for facility by PT to improve strength. Wound care evaluated patient. Patient has sacral/coccyx decubitus ulcer. Per surgery recs, too dry for debridement. Continue wound care recs at facility and e-consult was placed for outpatient surgery f/u.    Please see hospital course by problem below:    #ACUTE HYPOXEMIC RESPIRATORY FAILURE (9/19/2021) #CORONAVIRUS COVID-19 DISEASE (+Test 9/13/2021) #?SECONDARY BACTERIAL PNEUMONIA Presented from facility for cough, SOB, recent covid (+9/13) and RLL consolidation on CXR c/f secondary bacterial PNA. Afebrile and w/o leukocytosis on admission, started on covid treatment (steroids, Remdesivir, Toci) and empiric abx (Vanc 9/20-9/22, Cefepime 9/20-23), but with worsening respiratory status requiring HFNC 50L/80% FiO2. Now s/p Decadron 19/19, Solumedrol 125 q6 x4 days, Remdesivir x5 days, Toci x2 in ICU. CT chest showed moderate b/l effusions (exudative - gram stain/KOH neg for organisms), now s/p b/l chest tube placement with drainage. MRSA swabs neg, Vanc DC'ed. BCx NGTD. Pt now on 4L NC satting well, inflammatory markers improving. 9/24- s/p b/l chest tube removal, satting well on 4LNC, SOB and inflammatory markers improving. Cont Cefipime and steroid taper, wean O2 as able. S/p Cefepime 2g q8 x 7d (9/20-9/26). Inflammatory markers trending down. Breathing comfortably on RA.  -Cont steroid taper- Pred 50mg with daily 10mg taper as prescribed  -Follow up Toci labs: TB, strongyloides, Cocci -Continue COVID isolation precautions until 10/3  -Wean O2 as tolerated, goal SpO2 >94%    #ANASARCA #SCROTAL EDEMA Diffuse anasarca on initial presentation with significant scrotal and b/l LE edema. Cr at baseline (0.6-0.7), BNP baseline on admission.TSH wnl. ?Possibly 2/2 hypoalbuminemia, poor nutrition. Net (-)17L this admission at time of transfer to floor. 9/24- neg 6L yesterday, with LE and scrotal edema improving significantly. DC'd Diamox and Spiro, cont Lasix at current dose. Ctm Cr. Swelling continuing to improve, still net neg 1-2L yest without Lasix. Patient to discharge on reduced Lasix dose, 20mg PO daily.  -Continue Lasix 20mg PO daily  -Chem 7 in 2-3 days    #DM2 c/b osteomyelitis s/p L BKA on 9/11/2021 Last A1c 13.5 on 7/2021. Patient on PTA insular glargine 15 units BID, Metformin 500 4 tab QD. Increasing insulin requirement on high dose steroids. 9/24 - sugars 300-400s overnight 2/2 high dose steroids. Pt on 18u BID NPH, 8u regular TID prior and required 58u over past 24 hours in addition. Will increase basal to 38u BID, increase bolus to 10u TID, ctm sugars closely as we taper steroids. 9/25 - sugars 120s -- >80s this AM, decreased Insulin to 25 BID NPH, 10 TID regular mealtime. Hold AM mealtime given 80s. Ctm as steroids decrease. Sugars stable 140s, cont current regimen and ctm sugars. -Insulin regular 10u TID qAC   -NPH 25u BID basal -Continue to monitor sugars, taper steroids as abovel   #URINARY RETENTION S/p outpatient placement of indwelling foley 9/15. Swelling improving gradually per patient. S/p unsuccessful voiding trial yesterday, now with condom cath in place draining well. -Continue PTA Tamsulosin 0.4 mg PO daily    #HTN -Continue Lisinopril 2.5 mg PO daily (SBP 130s-140s, Cr WNL)   #HYPERLIPIDEMIA -Continue Lipitor 10 mg PO daily   #Wound Care  To coccyx wound will use wound gel to soften the eschar , but will protect periwound from moisture.    Wound 1: Sacrococcyx - Clean using Easicleanse washcloths, gently wash skin, pat dry. To periwound : protect with Critic aid barrier paste. To dark eschar: Apply Hydrogel wound gel and cover with xeroform gauze. Secure with Mepilex sacral border dressing. Change BID and prn soiling.  Waffle cushion under coccyx when in bed and up in chair.  Turning / Offloading every 2 hours in bed.       Left BKA - defer to Ortho recs, assess and cover with dry gauze daily .    Right heel - offload with pillow off the mattress.    Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  AHRF 2/2 COVID PNA