Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Acute respiratory failure, Anticoagulant therapy, Arterial catheterisation, Azotaemia
Clinical narrative: Hospitalized (2.18.22 - 2.21.22 =3 days/ Transferred to Facility 2/21.22 - still admitted); COVID-19 positive (2.16.22); fully vaccinated PLUS Booster - pfizer x2 2/18/22 H&P:  Chief complaint Cough, shortness of breath, COVID-19 Problem List Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Acute respiratory failure due to COVID-19    Hypertension   Assessment and Plan Medical Decision Making:   Patient seen examined in Emergency Department.  Patient currently is on high-flow at 95% O2 and 60 L both high-flow and non-rebreather mask for respiratory distress and failure.  Patient states that he originally got sick approximately 1 week ago with increasing flu-like symptoms including fever cough shortness of breath however on Wednesday last week he went to his PCP and was checked for COVID was positive.  Patient was called by his PCP and told to go to the ER today because of worsening shortness of breath and cough.  It was discussed with the patient regarding intubation and CPR patient agrees to both.  I did explain to him that it could possibly be a high likelihood that he would be intubated in the next 12 hours. -Acute respiratory failure due to COVID-19  Assessment & Plan Patient currently on high-flow oxygen as well as non-rebreather and acute respiratory failure.  Workup is positive for bilateral severe -COVID-19 pneumonia.  Will continue maximal respiratory supportive care and intubation if needed.  Left his evaluate admitting the patient to the critical care unit because of the current O2 requirements.  Patient has signs symptoms started last 7 days. -* Pneumonia due to COVID-19 virus Assessment & Plan Will plan maximal supportive care including intubation which was discussed with patient.  -Hypertension Assessment & Plan Will continue pre-hospital medications, will also keep on cardiopulmonary monitoring. History of Present Illness Patient is a 73 y.o. male  who presents to hospital emergency department with a history of positive COVID test and worsening respiratory distress.  He denies fevers chills nausea vomiting chest pain at home he denies abdominal pain, diarrhea.  Patient states he lives at home with his wife who is not sick.  Please see emergency department providers history of present illness listed below:   73-year-old male with past medical history that includes arthritis, BPH, cardiac murmur, hemorrhoids, dyslipidemia, hypertension, scoliosis, and thoracic aortic aneurysm, presents with shortness of breath in the setting of a positive COVID test on February 16th of this year.  Patient states that he was diagnosed with COVID on Wednesday.  Had upper respiratory symptoms about a week prior.  Cough/cold/rhinorrhea/sore throat/shortness of breath.  Denies chest pain.  Worsening shortness of breath this morning, called EMS, 60% on arrival of 1st responders per report.  Non-rebreather upon arrival, high 80s.  States has history of valvular heart disease.  Denies weight gain or edema.  Denies nausea, vomiting, or diarrhea.  Some lightheadedness, dizziness, and balance disturbance due to shortness of breath.  No focal weakness.  Is vaccinated. Objective BP 151/57  | Pulse 86  | Temp 37 °C (Oral)  | Resp (!) 37  | Ht 1.854 m  | Wt 103.1 kg  | SpO2 (!) 88%  | BMI 29.99 kg/m²  FIO2 (%): 95 % Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is in acute distress.     Appearance: Normal appearance. He is normal weight. He is ill-appearing.     Comments: Patient is in respiratory distress.  He seen examined lying in a right decubitus position.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Mouth/Throat:     Mouth: Mucous membranes are dry.  Eyes:     General: No scleral icterus.    Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard.   No gallop.  Pulmonary:     Effort: Respiratory distress present.     Breath sounds: Rhonchi present.     Comments: He has significantly diminished bilateral breath sounds and bilateral rhonchi. Chest:     Chest wall: No tenderness.  Abdominal:     General: There is no distension.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.     Comments: Patient is able to answer questions in 3 and 4 with sentences.   2/21/22 transfer/d/c summary:   Discharge Summary BRIEF OVERVIEW:   Discharge Provider: DO Primary Care Provider at Discharge: MD   Admission Date: 2/18/2022                      Discharge Date: 2/21/2022 Active Hospital Problems   Diagnosis Date Noted POA ? Shock   02/20/2022 Yes ? AKI on CKD stage IV 02/19/2022 Yes ? Acute respiratory failure due to COVID-19, 2/16/2022 02/18/2022 Yes ? Pneumonia due to COVID-19 virus, 2/2022 02/18/2022 Yes ? Dilated cardiomyopathy 07/14/2021 Yes ? Hypertension   Yes ? Hyperlipidemia   DISCHARGE DISPOSITION: transfer to Hospital DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute respiratory failure with hypoxia [J96.01] Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1]   HOSPITAL COURSE: 02/18:Patient is a 73 y.o. male  who presents to hospital emergency department with a history of positive COVID test and worsening respiratory distress.  He denies fevers chills nausea vomiting chest pain at home he denies abdominal pain, diarrhea.  Patient states he lives at home with his wife who is not sick.  Please see emergency department providers history of present illness listed below:   Patient seen examined in Emergency Department.  Patient currently is on high-flow at 95% O2 and 60 L both high-flow and non-rebreather mask for respiratory distress and failure.  Patient states that he originally got sick approximately 1 week ago with increasing flu-like symptoms including fever cough shortness of breath however on Wednesday last week he went to his PCP and was checked for COVID was positive.  Patient was called by his PCP and told to go to the ER today because of worsening shortness of breath and cough.  It was discussed with the patient regarding intubation and CPR patient agrees to both.  I did explain to him that it could possibly be a high likelihood that he would be intubated in the next 12 hours.  Patient did have worsening status after arrival to critical care unit 4, was tachypneic overnight and decreasing SaO2 84-88% with respirations in the mid 30s.  Patient did drop significantly when ambulating or going to bedside commode or movement.   02/19:  Patient's wife was contacted in the morning and patient's son arrived to the hospital and was discussed patient's current respiratory status and the need for intubation and ventilatory support.  This was also discussed with the patient in the emergency room and again this morning prior to intubation.  RSI and MAC sedation was used for intubation patient was intubated/11:00 a.m..  After appropriate sedation and paralytics or administer patient was prone for functionally 16 hours.  Patient's respiratory status remains stable overnight, even slightly improved with decreasing FiO2 requirements.  However patient had worsening urinary output overnight and was +1200 mL.  Additionally patient's BUN and creatinine is elevated at 76 and 2.77 respectively.   02/20:  Patient required epinephrine added to the no epinephrine overnight.  Additionally patient was discussed with the VICU provider Dr., will hold diuretics currently monitor urine output if BUN creatinine and urine output continue to worsen and potassium level elevates, patient will require transfer to hospital for most likely CRRT.  Patient's repeat creatinine at 3:00 a.m. in the afternoon is 3.09 BUN is 87 pH however is improved to 7.3 with a bicarb drip.  Again no Lasix recheck and evaluate tomorrow patient will be phoning tonight.  Patient only has minimal improvement in oxygenation and almost no improvement and PF ratio.  If need be patient may remain in supine position if no improvement with proning.    2/21:  Patient seen this morning stable from a respiratory standpoint but his renal function continues to decline with a creatinine up to 3.55, creatinine clearance of 17. His urine output is also declining.  Discussion with Critical Care lead to a recommendation for transfer for CRRT.  Spectrum direct was contacted and arrangements were made for the patient to transfer to Hospital Medical intensive care unit for ongoing critical care and dialysis.  CONSULTS / RECOMMENDATION:  VICU - See progress note INPATIENT PROCEDURES: Endotracheal intubation with Mechanical ventilation Placement of triple-lumen venous catheter and arterial line   BP 117/51  | Pulse 76  | Temp 36.2 °C (Bladder)  | Resp (!) 36  | Ht 1.854 m  | Wt 99.9 kg  | SpO2 97%  | BMI 29.06 kg/m²  FIO2 (%): 60 % Physical ExamVitals and nursing note reviewed.  Constitutional:   Appearance: He is well-developed and well-nourished.     Interventions: He is sedated and intubated.  HENT:      Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Oropharynx is clear and moist.     Comments: ETT and OGT in place Eyes:     Extraocular Movements: EOM normal.  Cardiovascular:      Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses and intact distal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: He is intubated.     Comments: Mechanical breath sounds without significant rales or rhonchi Abdominal:       Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Skin:      General: Skin is warm and dry.     Findings: No rash.  Neurological:  Deep Tendon Reflexes: Reflexes are normal and symmetric.  Psychiatric:     Mood and Affect: Mood and affect normal.  2/28/22 MICU progress note:CHIEF COMPLAINT: Pneumonia due to COVID-19 ASSESSMENT / PLAN: Patient is a 73 y/o male with a past medical history of HTN, HLD, dilated cardiomyopathy w/ EF 44%, thoracic aortic aneurysm, and LBBB who initially presented at Hospital on 2/18 with dyspnea secondary to COVID-19. He reportedly developed symptoms a week prior to his confirmed diagnosis on 2/16. When EMS arrived to his house, he was found to be saturating at 60% and required non-rebreather and HFNC at 95% on 60L. On 2/19, patient continued to decompensate and required intubation along with initiation of vasopressors; NMB 2/19-2/20, prone positioning started 2/19.  On arrival, noted AKI with Cr of 1.9, azotemia but throughout hospital course quickly progressed to a creatinine above 3.5 on 2/21. Failed trial lasix, CRRT started 2/27.  S/p bronch with BAL on 2/22, NGTD. 2/22 NMB resumed with prone/supine positioning. Marked leukocytosis, flow cytometry consistent with B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma.     Plan for today 2/28:  Prone 18:6 Plan to supine @ 2100 Please obtain ABG prior to supinating-also plan to obtain ABG prior to proning (will evaluate further need to prone) Plan to keep paralyzed Consult hematology-New diagnosis of CLL and right flank skin rash would appreciate recommedations *spoke with wife today, she states that the patients brother has a new diagnosis of CLL in the last month CRRT -100 Beta D pending    A/P Acute hypoxemic respiratory failure ETT: 2/19-present NMB: 2/19-2/20, 2/21- FIO2 (%): 60 % Type of Mechanical Vent: Hamilton Mechanical Rate: 34 breaths/min Set/Target Tidal Volume: 440 PEEP (cm H2O): 12 cm H2O Inspiratory Time Set: 0.88 second(s) Sedation: propofol, fentanyl, versed LPV with TV ~6 mL/kg (480) with goal of PaO2 55-80, plateau < 30 Prone (20:4) 2/19-2/24; (18:6) 2/24-2/26; (18:6) 2/28/-present   COVID-19 pneumonia Fully vaccinated, received booster 11/19/21 Diagnosed 2/16, admitted 2/18, intubated 2/19 Remdesivir 2/18-2/20, stopped due to AKI Steroids              Decadron 6mg daily 2/18-2/19              Methylprednisolone 50mg BID 2/19-2/24              Methylprednisolone 50mg daily 2/25-   AKI on CKD stage IIIb Azotemia Baseline Cr 1.4-1.5 Cr on admit 1.88-- >3.55 on 2/21 requiring transfer to SHBL for possible RRT Holding - Lasix gtt started PM 2/22-2/25 - improved UOP Renal ultrasound NEG Nephrology following CRRT 2/27-present   Leukocytosis    New diagnosis Chronic Lymphocytic Leukemia Pathologist review on 2/22 felt that lymphocyte morphology could be indicative of concurrent lymphoproliferative neoplasm 2/24 flow cytometry concerning for chronic lymphocytic leukemia, small lymphocytic lymphoma Hematology consulted   Hyperglycemia   A1C-6.2 q4hr BG, Basal/bolus/SSI   Thyroid mass (2.5x 3.2 x 4.4cm) RUL mass (pleural based 13mm x 9.8mm x 17mm) on CT Thorax 1/7/22 Will need follow up when stabilized   Nonischemic dilated cardiomyopathy (2021) Last echo on 10/2021 shows EF 44% Maintained on coreg, lisinopril, HCTZ at home Bilateral renal cysts    Ultrasound demonstrating enlarged kidneys bilaterally Due to unclear images, nephrology recommending further imaging with MRI when stable Hypertension   Home meds held due to pressor requirements Hyperlipidemia  Home statin held Thoracic aortic aneurysm (2015) Stable in size at 4.4cm per most recent echo on June 2021 Optimize blood pressure to prevent accelerated hypertension Shock-RESOLVED    Likely secondary to sepsis Febrile, WBC of 43.4 on 2/19 Initially on norepi and epi started on 2/19 Norepi off 2/22, needed again when supine  Blood cultures NGTD, urine cx NGTD, negative urine legionella/strep Empiric Zosyn, vancomycin stopped 2/20 for negative MRSA swab Right flank skin rash    Would appreciate hematology to comment on flank rash Picture in media tab under wound image 2/28 May need punch biopsy Prophylaxis: VAP- chlorhexidine GI- pepcid DVT- subcutaneous heparin Nutrition:   NPO   Tube feeds via post pyloric Corpak   Lines:   R radial arterial line 2/19-present R IJ CVC 2/19-present Left IJ Vascath 2/27-  Drains:   Foley 2/19-present OG 2/19-present  Airways:   ETT 2/19-present  Antibiotics:   Vancomycin 2/18-2/20 Zosyn 2/18-2/23  Code status: Full code - per note documenting discussion with patient on 2/18  OBJECTIVE: BP (!) 186/82  | Pulse 101  | Temp 37.3 °C (Bladder)  | Resp (!) 34  | Ht 1.854 m  | Wt 101.7 kg  | SpO2 92%  | BMI 29.59 kg/m²  FIO2 (%): 60 %