Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Blood lactic acid increased, Blood pressure systolic decreased, Brain natriuretic peptide increased, Bronchitis, Bundle branch block right
Clinical narrative: Patient currently admitted at (3) days for inpatient treatment. H& P: Patient is a 80 y.o. male with past medical history chronic thromboembolic pulmonary hypertension after saddle embolus in 2016 on 2 L of oxygen baseline, recently diagnosed myelodysplastic syndrome and type 2 diabetes who presented with acute hypoxic respiratory failure due to COVID-19 pneumonia.   Patient reports that 3 days prior to presentation he started having significant shortness of breath, cough as well as having diarrhea for couple of days.  He also notes chills and significantly decreased appetite and fatigue.  On the day admission he called EMS who found him at home with oxygen saturation 50%.   Of note on 12/1 patient was diagnosed with bronchitis started on prednisone 20 mg for 5 days.  He notes that this would be the last day of steroid treatment.   When brought to the emergency room he was initially started on high-flow nasal cannula, however he did not tolerate this well and became agitated and said there put on BiPAP.  He is also given DuoNeb treatment due to wheezing heard on exam and 10 mg Decadron.  The patient was febrile on presentation and tachycardic.  Chest x-ray was obtained which was consistent with COVID pneumonia and COVID PCR was positive.  Lab evaluation was significant for BNP elevated to 7000 when previously was normal, initial lactic was elevated to 2.6 but then decreased to 1.5.  Also noted was a low hemoglobin of 7.3, however patient has been recently diagnosed with myelodysplastic syndrome and this lab finding has been stable since August.  White blood cell count was not significantly elevated at 4.14.    Troponins were collected and had a delta 103. The emergency department did discuss with Cardiology who recommended ordering an echo and starting high-intensity heparin drip for a possible PE.  EKG showed atrial fibrillation with right bundle-branch block with no significant ST elevation or depression.  CTA was not obtained due to elevated creatinine.   The patient reports feeling significantly improved after the initiation BiPAP and son confirms that patient looks more comfortable.   Of note the patient had received 2 COVID vaccines.  He was waiting to receive the booster vaccine until he was able to talk with hematologist in light of his recent diagnosis of myelodysplastic syndrome.  Unfortunately, he became ill before this discussion could take place.  Plan: Patient is an 80 male with past medical history chronic thromboembolic pulmonary hypertension after saddle embolus in 2016 on 2 L of oxygen baseline, recently diagnosed myelodysplastic syndrome and type 2 diabetes who presented with acute hypoxic respiratory failure due to COVID-19 pneumonia.   Acute on chronic Hypoxic Respiratory failure secondary to COVID-19 pneumonia Prior saddle embolus in 2016 leading to chronic thromboembolic pulmonary hypertension on long term xarelto and requiring 2L of O2 with activity and nightly CPAP. Now with hypoxia requiring BIPAP secondary to COVID-19 infection.  - BiPAP, wean as tolerated - Methylprednisolone 40 mg BID, can wean to decadron 6mg as patient improves - Remdesivir 200mg now and then 100mg daily for 5 days total - Daily CMP, CBC, CRP, D-dimer - NPO, on IVF (1mL/kg/hr)  while on BiPAP due to concern for decompensation - blood cultures pending   CTEPH (Chronic thromboembolic pulmonary hypertension)  Concern for possible PE Elevated Troponin Patient with in 2016 leading to CTEPH requiring supplemental oxygen at baseline.  Now with hypoxia down to 50% saturation requiring BiPAP.  Due to significant hypoxia as well slightly elevated D-dimer to 590, significant history of prior PE, significantly elevated troponin, concerned that he could PE now. - Trend troponins q6 hours, can discontinue once improving - Obtain CTA - Per cardiology recommendations, start heparin gtt - Echo pending - Cardiology consult in light of elevated troponins and concern for right heart strain - continue home Adempas   Anemia due to myelodysplastic syndrome Patient being followed with Hematology due to various cytopenias including low hemoglobin.  Recently diagnosed with myelodysplastic syndrome the bone marrow biopsy.  Hemoglobin on admission 7.3 which is stable over the last several months. - Follow with daily CBCs - transfuse if less than 7   Hypertension - Hold home losartan in setting lower systolic blood pressures in 130s and with slightly elevated creatinine   CKD stage 3 Elevated creatinine Creatinine on admission 1.67, previously on 11/10 was 1.69 and in 08/2021 was 1.54. Creatinine not significantly elevated from baseline. Does not meet criteria for AKI - will monitor daily in light of remdesivir and receiving contrast with CTA - hold home losartan for now   Diabetes Mellitus type 2 Last HbA1c on 11/10/21 4.9. On metformin at home - 24 hour corrective insulin   Fluids: Normal Saline at 100 mL/hr (being cautious in light of pulmonary hypertension and lower extremity edema)  Diet: NPO while on BIPAP Lines/Tubes/Drains: PIV DVT Ppx: treatment heparin gtt Code Status: full Dispo: Admit to inpatient