Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Angiogram pulmonary normal, Aspergillus test negative, COVID-19, COVID-19 pneumonia
Clinical narrative: Date of Admission  01/25/2022   Date of Discharge  02/22/2022   Reason for Hospitalization   Dyspnea, SARS-CoV-2 Pneumonia  From Admission H&P on 1/25/22 by Dr.: Patient is a pleasant 59-year-old female who is vaccinated for Covid, past medical history of vasculitis [unclear etiology we will send for records] requiring Rituxan infusions every 6 months.  Patient presents to the ED today complaining of dizziness patient has tested positive for Covid on 1/16, symptoms started on 1/14.  Patient reports initial symptoms were shortness of breath, productive cough of yellow-greenish sputum, fever reaching a max of 100.3, chills, and diarrhea.    Vital signs in the ED were stable apart from requiring 6 L nasal cannula to maintain saturation of 94%, CT PE was done which was negative.  We will admit the patient for new O2 requirement and start on dexamethasone, remdesivir.     Hospital Course   Patient is a 59 year-old Female with a past medical history of Granulomatosis with Polyangiitis (on Rituximab and Prednisone), HTN, and Depression, who presented to Facility on 1/25/22 with Dyspnea and Fever, found to have SARS-CoV-2 Pneumonia. Patient reportedly tested positive on 1/16/22 with symptom onset on 1/4/22, and also tested positive on admission. Patient was vaccinated and received a booster, but was on chronic immunosuppression. Patient had increasing oxygen requirements and on 1/26/22 was transferred to the Facility for Acute Hypoxic Respiratory Failure secondary to SARS-CoV-2 Pneumonia. Patient received a 5 day course of Dexamethasone and Remdesivir and was able to be downgraded on 1/28/22. Hospital course was complicated by persistent fever and oxygen requirement. Rheumatology consulted, however stated that unlikely vasculitis contributory to current clinical course. Concern for superimposed infection in the setting of immunosuppression and ID was consulted for further recommendations. Initial fungal work-up negative, however patient was persistently febrile with continued oxygen requirement and was started on broad spectrum coverage with Vancomycin and Meropenem to complete a 7 day course. CT Chest PE 2/10/22 with no pulmonary embolism and had unchanged bilateral airspace disease, while CT Abdomen/Pelvis revealed no acute intra-abdominal or pelvic findings. ECHO 2/11/22 with EF of 63%, normal systolic function and no regional wall motion abnormalities. Pulmonology consulted and it was thought that patient will likely have a long-term oxygen requirement as the result of SARS-CoV-2 infection in the setting of prior pulmonary involvement from known Granulomatosis with Polyangiitis. Patient was started on Breo Ellipta and also received diuresis to help address any fluid overload. Patient had several Home Oxygen evaluations with continued improvement in oxygen requirements, with last evaluation on 2/22/22 revealing a 2-3 L requirement with rest and 4-5 L requirement with exertion. Patient with persistent tachycardia, worse with exertion, thought to be from deconditioning from prolonged hospital stay. Patient was discharged to Home on 2/22/22 in stable condition with Home Oxygen, Home Health Services, and planned outpatient follow-up with Pulmonology, Rheumatology, her PCP, as well as Pulmonary Rehabilitation. Patient advised to continue aggressive incentive spirometry and close monitoring of oxygenation and respiratory status, and call EMS and/or present to the nearest ED with any concerning signs or symptoms. Patient verbalized understanding with treatment plan and all questions and concerns were addressed.     Discharge Diagnoses       Acute Hypoxic Respiratory Failure  SARS-CoV-2 Pneumonia  - Reportedly tested positive for SARS-CoV-2 on 1/16/22, symptom onset on 1/4/22, positive on admission 1/25/22  - Vaccinated prior to admission, however was on immunosuppression for GPA  - Required ICU admission for increased work of breathing, facility  - Received Dexamethasone (1/26 - 1/30) and Remdesivir (1/25 - 1/29)  - CT PE x 2 on 2/5/22 and 2/10/22 with persistent bilateral airspace disease, negative for PE  - CT CT Abdomen/Pelvis 2/10/22 revealed no acute intra-abdominal or pelvic findings  - Infectious work-up unremarkable, including negative cultures, Histo, Fungitell, Aspergillus Ag, HIV, Hep Panel  - Negative RPP x 2, negative MRSA PCR  - Previously treated for CAP with Azithromycin and Ceftriaxone, and later 7 day course of Vancomycin and Meropenem  - Pulmonology consulted, suspected that will require long-term oxygen - Discharged on Breo Ellipta  - Discharged with Home Health Services  - Discharged on Home Oxygen (2-3L at rest, 4-5L with exertion), encourage ISB, ambulation as tolerated  - Outpatient follow-up with Pulmonology  - Outpatient Pulmonary Rehabilitation  Granulomatosis with Polyangiitis  - Continue home Prednisone 7.5 mg daily at home, Rituximab infusions q6h months - Outpatient follow-up with Rheumatology  HTN  - Continue Lisinopril 20 mg daily - Outpatient follow-up with PCP  Chronic Pain  - Continue Duloxetine 60 mg BID  - Continue Gabapentin 300 mg BID, 600 mg qHS - Outpatient follow-up with PCP     Other Diagnoses   Ongoing  BMI 40.0-44.9, adult   Operations and Procedures   None     Consultants  Medicine Immunology Rheumatology    Medicine Infectious Disease    Medicine Pulmonary    Pending Labs  AFB Blood Culture (Preliminary, InProcess, ordered 02/09/2022, 16:43)   Blood Fungal Culture (Preliminary, InProcess, ordered 02/09/2022, 16:44)      Discharge Disposition  Home with Home Health     Medications  New, Changed, or Refilled Medications  fluticasone-vilanterol (Breo Ellip 1 Inhalation, Inhalation, Daily, 1 Each, 0 Refill(s)      Medications to be Continued  DULoxetine (Cymbalta 60 mg oral de 60 mg, 1 capsule(s), Oral, bid, 0 Refill(s)    aspirin (aspirin 81 mg , chewable) 162 mg, 2 Tablet(s), Oral, At Bedtime    calcium carbonate/famotidine/Mg hy 1 Tablet(s), Oral, q12h    calcium-vitamin D (Calcium 600+D) 1 Tablet(s), Oral, bid, 0 Refill(s)    gabapentin (gabapentin 300 mg) 300 mg, 1 capsule(s), Oral, bid    gabapentin (gabapentin 300 mg) 600 mg, 2 capsule(s), Oral, At Bedtime    lisinopril (lisinopril 20 mg) 20 mg, 1 Tablet(s), Oral, Daily, 0 Refill(s)    multivitamin (B-Complex with B-12) 1 Tablet(s), Oral, Daily    predniSONE (predniSONE 5 mg) 7.5 mg, 1.5 Tablet(s), Oral, Daily, 0 Refill(s)    riTUXimab (Rituxan) See Instructions, IV every 6 months. Pt unsure of dose., 0 Refill(s)  Instructions:IV every 6 months. Pt unsure of dose.    Discontinued Medications  alendronate (Fosamax 70 mg) 1 Tablet(s), Oral, qSunday, 12 Tablet(s), 0 Refill(s)    celecoxib (CeleBREX 200 mg) See Instructions, 1 capsule(s) Oral bid x 3 days, then 200 mg QD x 10 days, 16 capsule(s), 0 Refill(s)       Physical Exam at Discharge  Vitals & Measurements  T: 36.2 °C  TMIN: 36.1 °C  TMAX: 36.3 °C  HR: 100  RR: 9  BP: 92/71  SpO2: 94%  WT: 104.8 kg  BMI: 40.6      General: Lying in bed in no acute distress. HEENT: Head normocephalic, atraumatic. No scleral icterus. Trachea midline. Cardiovascular: Tachycardic, regular rhythm. Normal S1 and S2. Pulmonary: Breath sounds appreciated bilaterally. Normal work of breathing with supplemental O2 via NC. Abdomen: Soft, non-distended, no tenderness to palpation. Bowel sounds appreciated. Musculoskeletal: No evidence of gross limb deformities. No evidence of peripheral cyanosis. Neuro: Alert and Oriented. No evidence of focal neurological deficits. Psych: Normal mood and affect. Responds appropriately and cooperative with examination.  Skin: Warm, dry.     Time Spent  Over 35 Minutes      Follow Up Appointments     Follow Up Appt Medicine General, Clinic Name/Phone: Other - see comments, Provider Name: FNP, Within 7 Days, No tests, Comments Moberly Physicians Family Medicine   Follow Up Appt Medicine Immunology Rheumatology, Clinic Name/Phone: Center for Rheumatic Diseases, Provider Name: NO , PREFERENCE, Within 14 Days, No tests   Follow Up Appt Medicine Pulmonary Adult, Clinic Name/Phone: Pulmonary Medicine Clinic, Provider Name: NO , PREFERENCE, Within 1 Month, No tests         With  When  Contact Information        Follow up with your Primary Care Provider within 1 week Within 5 to 7 days   Additional Instructions: You must contact this provider to schedule your appointment.         Addendum by MD, on February 25, 2022 12:03:41 CST (Verified)    I personally saw and evaluated the patient on the result date found in the header of this document.  I independently performed the critical/key portions of the Evaluation and Management service and discussed the management with the author of this document.  I agree with everything documented above with the following exceptions/additions: none   more than 35 mins spent in dc planning, med rec, care coordination and documentation