Age: 79.0
Sex: M
Vaccine: COVID19-2, FLUA4
Symptoms: Dyspnoea, Echocardiogram abnormal, Hypophagia, Hypotension, Hypothermia
Clinical narrative: COVID+ 1/10/23.  Vaccination status - pfizer x4 + Pfizer bivalent x1 BRIEF OVERVIEW: Discharge Provider: * Primary Care Provider: DO Admission Date: 1/10/2023 Discharge Date: Jan 16, 2023   Active Hospital Problems   Diagnosis Date Noted POA ? Vitamin D deficiency 01/16/2023 Yes ? Acute systolic heart failure 01/16/2023 Yes ? Idiopathic hypotension--patient totally asymptomatic, arterial line blood pressures correlating better with calf pressure 01/16/2023 Yes ? Incidental lung nodule, greater than or equal to 8mm--right upper lobe (9 mm), will need repeat CT in 3 months 01/16/2023 Yes ? Weight loss, abnormal    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Severe sepsis [A41.9, R65.20] Pneumonia of right lower lobe due to infectious organism [J18.9] COVID-19 [U07.1] Sepsis [A41.9] Septic shock [A41.9, R65.21] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: Patient is a 79-year-old male with PMH significant for COPD, former tobacco abuse, ongoing cannabis abuse, severe paraseptal/centrilobular emphysema, CKD stage 3, history of neuroendocrine tumor (status post gastrectomy), history of bowel perforation after a bout of diverticulitis needing colostomy and subsequent takedown, depression/anxiety, chronic pain, BPH--presents to the hospital on 01/10 with 4 days symptoms of generalized weakness, poor oral intake, poor mobility, increasing dyspnea and chronic concerns of anorexia/25 lb weight loss. He was noted to be hypotensive in ER with systolics in 70s requiring IV fluid resuscitation, tested positive for COVID-19, chest x-ray showed COPD but no infiltrates.  Patient was admitted for systemic symptoms related to COVID-19 infection.   Patient was noted to have hypotension that did not respond with IV fluid resuscitation, even after 5 L. patient intermittently had low-grade lactic acidosis but he remained totally asymptomatic during the entire stay from a blood pressure standpoint.  Given his hypothermia, tachycardia and tachypnea associated with lactic acidosis, it was determined that he did have essential elements to call for severe sepsis.  When his lactic acid reached 3.7, he was transferred to intensive care unit and had arterial line placement for blood pressure monitoring, it was correlating more closely with calf blood pressures.  He needed peripheral norepinephrine briefly but this was discontinued an arterial line was also discontinued and transferred out of intensive care unit.  Continued to have a a few episodes of hypotension but again asymptomatic.   Echocardiogram further evaluate was done, showed mild systolic HF with EF 45-50%, possibly suspicious for stress-induced cardiomyopathy.  Cardiology consultation was requested but not available for several days due to holiday weekend and patient did not want await any further.  Will need outpatient follow-up with Cardiology.  Did prescribe him p.r.n. Lasix for weight gain and lower extremity edema but given his blood pressure situation, I did not feel comfortable discharging him on GDMT.   He did have bilateral lung infiltrates, ground-glass opacities, most notably in left lower lobe could be a combination of COVID-19 infection.  Unable to rule out a superimposed bacterial infection and hence patient completed 5 days of Rocephin and 3 days of azithromycin.   Given his severe paraseptal/centrilobular emphysema, and ongoing cannabis use, patient was started on Spiriva and was given a rescue inhaler with albuterol.  He was also counseled about cannabis cessation but he was not interested, ?it is something that I enjoy in my life?.  If finished remdesivir course, was given a dexamethasone prescription to finish a 10 day course.   Patient's wife was quite concerned about  his anorexic behavior at home.  However patient denies that he is anorexic, he tries to maintain his weight between 120-125 lb but with recent illnesses, he lost 7-10 lb.  His oral intake had improved during his hospital stay.   Imaging studies showed ileus, patient was not symptomatic from this.  He was able to tolerate oral diet and also had bowel movements.   He was noted to be vitamin-D deficient, was given prescription   He was ultimately discharged home on 01/16.   He needs a repeat CT in about 3 months for his speculated right upper lobe nodule.   (This was not included in the discharge paperwork, however patient called at 5:22 p.m. today and updated him which she wrote down)   Consultations: Intensive care unit Cardiology but needs to follow-up as outpatient   Procedures: Arterial line placement Echocardiogram CT angiogram thorax-negative for PE, showed multifocal pneumonia, left lower lobe predominant, severe emphysema and incidental spiculated 9 mm right upper lobe pulmonary nodule. CT abdomen--bibasilar airspace disease, bowel gas pattern consistent with ileus