Age: 51.0
Sex: F
Vaccine: COVID19
Symptoms: Hypoxia, Imaging procedure, Indeterminate investigation result, Interstitial lung disease, Malaise
Clinical narrative: Hospitalized (1.22.22 - 1.24.22); COVID-19 positive (1.22.22); Fully vaccinated -pfizer x2 d/c summary:ED to Hosp-Admission Discharged   1/22/2022 - 1/24/2022 (2 days)   MD   Last attending ? Treatment team Acute respiratory failure with hypoxia (HCC)   Principal problem   Discharge Summary MD (Physician) ? ? General Medicine  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 1/22/2022 Discharge Date: Jan 24, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? Acute respiratory failure with hypoxia (HCC) 01/23/2022 Yes ? Tobacco abuse 01/22/2022 Yes ? COVID-19 virus infection 01/22/2022 Yes ? Interstitial lung disease (HCC)   Yes ? History of pulmonary embolism 09/28/2016 Yes ? Depression   Yes ? Generalized anxiety disorder   Yes ? GERD (gastroesophageal reflux disease)   Yes   Resolved Hospital Problems No resolved problems to display. Discharge Disposition:  home or self care  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: COVID-19 [U07.1] Acute respiratory failure with hypoxia (HCC) [J96.01]   HOSPITAL COURSE:   The patient is a 52 yo woman who was admitted to the Hospital 1/22/22 with worsening respiratory difficulty over the past week associated with hypoxic episodes at night. She noted home pulse ox values as low as the 50s per her recall.  She had gotten 2 Covid vaccines, the last being 8/2021 but on arrival to the ER, tested positive for Covid infection.   She is obese BMI 38.89 with likely untreated OSA in need of an outpatient sleep study.  She has hx of respiratory problems described as interstitial lung disease on CT thorax about a year prior, has history of pulmonary embolism, and longstanding ongoing smoking with a possible history of chronic obstructive pulmonary disease for which she uses inhalers.   In the ER, she was hypoxic on room air, improved w/ oxygen.  She described symptoms consistent with Covid infection for about a week.  She was not aware of any specific exposure.  CTA thorax was without support for PNA or PE.  A stable solid nodule was noted.  There was no imaging support for COPD despite tobacco hx. BNP was elevated at 1,970 (5 - 900).   Acute hypoxic respiratory failure and a possible pericardial effusion on CT led to review of echo from 10/31/21, EF 71%, indeterminate diastolic fnx. It was quite possible she was suffering hypoxia from Covid infection so Decadron was given while in the hospital. She described exasperation with the circumstances, said she misunderstood she was supposed to use oxygen at night after a hospital stay from 10/2021 but confusion over her need to call respiratory therapy services.  Because hypoxia seemed out of proportion to CTA and her Covid story, an echo was sought with bubble study to assess for possible shunt but the study had challenging windows so was not informative. The effect of Lasix x1 was met with significant distress, said she would never agree to such a med again.  Any attempt to explain reasoning was not heard.   Covid infection was suspected to be a true positive but she had no support for PNA on imaging, something that is sometimes found despite hypoxia.  CRP 4 argued against this infection being a concern, however.  D-dimer was only slightly elevated above normal range at 610 (0 - 500).  Decadron was given during her stay but not scribed at discharge.  Pulmonary Rehab recommended 3 liters oxygen at rest and sleep, 4 with activity.   She was aware of her need for an outpatient sleep study. Tobacco use disorder was ongoing, cessation advised, and Symbicort BID was continued. Back pain, attributed to the hospital bed per pt, was treated with topical lidocaine and Tylenol   She discharged home with oxygen 1/24/22. CONSULTS None PROCEDURES Echo with bubble study, poor windows so unable to determine if shunt   BP 124/63  | Pulse 76  | Temp 36.6 °C (Oral)  | Resp 20  | Ht 1.651 m  | Wt 106 kg  | SpO2 94%  | BMI 38.89 kg/m²  FIO2 (%): 50 % Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is obese. She is not ill-appearing or toxic-appearing.  HENT:     Nose: Nose normal.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.     Comments: 3 liter O2 NC Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert. Mental status is at baseline.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Behavior: Behavior normal.     Comments: Tearful, wants to go home, upset about Lasix   H&P:  CHIEF COMPLAINT:Acute respiratory failure with hypoxemia (HCC) ASSESSMENT / PLAN: * Acute respiratory failure with hypoxemia (HCC) Assessment & Plan Patient has been ill about a week and have been using an oximeter at home and noted low oxygen levels at night in the past few days.  Her PCP attempted to arrange for home oxygen without success and she presents now to the emergency department for further evaluation.  She is found to O2 sat of 88% on room air.  A COVID-19 PCR was positive.  Patient has a past history of interstitial lung disease, tobacco abuse, and possible chronic obstructive pulmonary disease.  Is likely she is experiencing acute respiratory failure from COVID superimposed on pre-existing lung disease   Will continue the patient on her usual inhalers addition to treatment for COVID.   COVID-19 Assessment & Plan Patient has had a 1 week history of nonproductive cough, extreme fatigue, in worsening shortness of breath.  She is not aware of any COVID exposure.  She has had her initial two COVID vaccines but has not had a booster.  COVID-19 study is positive in the emergency room today.  Patient is mildly hypoxic on room air.  Will treat her with dexamethasone, she is probably outside the window of benefit with remdesivir.  If she continues to require only 2-4 L of O2 by nasal cannula for maintenance of oxygen level she may be able to transition to home COVID-19 therapy.   Interstitial lung disease (HCC) Assessment & Plan Patient had a CT of the chest about a year ago at which time interstitial lung disease was noted on the CT.  Is not clear if she had any additional investigation of ILD.   Tobacco abuse Assessment & Plan Patient has had longstanding tobacco abuse has not previously been motivated to stop smoking, in light of her hypoxia she now indicates willingness to consider tobacco cessation   History of pulmonary embolism Assessment & Plan Patient had an isolated episode of pulmonary embolism in 2016. Is not clear whether this is a provoked or unprovoked PE she is treated with warfarin has had no recurrent problems since then.   In light of past history of pulmonary embolism and current COVID infection patient is at increased risk for thromboembolic disease.  At this point we will treat with prophylactic Lovenox dosing.  Will monitor inflammatory markers C-reactive protein and D-dimer and consider CT angiogram in the event of increasing O2 requirements normal elevation of D-dimer.   GERD (gastroesophageal reflux disease) Assessment & Plan Patient has had longstanding reflux she has recently switched from another medication Protonix she is not sure whether not the Protonix is more helpful.  Will continue Protonix for now and Tums for breakthrough symptoms.   Depression Assessment & Plan Not currently on antidepressant medication   Generalized anxiety disorder Assessment & Plan Patient has had longstanding anxiety and has received multiple anti depressant anti anxiety agents without significant improvement.  He does use periodic dosing of Klonopin which she states is only mildly helpful. Subjective    HISTORY OF PRESENT ILLNESS: The patient is a 52 y.o. female who presents today with patient presents with worsening respiratory difficulty over the past week associated with hypoxic episodes at night.  She was evaluated in the emergency room and found to be hypoxic on room air with positive COVID study.  Patient has been symptomatic with symptoms consistent with COVID for about a week.  She is not aware of any specific exposure to individuals with COVID.  Patient has past respiratory problems with findings described as suspected interstitial lung disease on a CT scan about a year ago, has history of pulmonary embolism, and longstanding smoking with a possible history of chronic obstructive pulmonary disease for which she uses inhalers.. Review of Systems Constitutional:  Negative for activity change, appetite change, chills and fatigue.  HENT: Negative for ear discharge, hearing loss, nosebleeds, hoarse voice and trouble swallowing.  Eyes: Negative for eye discharge, itching and visual disturbance.  Respiratory:  Positive for cough, wheezing, shortness of breath and sputum production.   Cardiovascular:  Negative for chest pain.  Gastrointestinal:  Negative for heartburn, nausea, vomiting, abdominal pain, constipation and trouble swallowing.  Musculoskeletal:        Patient has chronic knee and back pain for which she takes Norco on a regular basis.  Neurological:        Patient has a history of migraines not currently having difficulty with migraines.  Endo/Heme/Allergy:        No history of diabetes or thyroid disorders.  Psychiatric/Behavioral:  Positive for depression and anxiety.  Skin:        Patient has had chronic edematous skin changes in the periareolar area of her breasts.  This has previously been evaluated biopsied and no evidence of inflammatory breast cancer was found.  The skin changes subsided for a period of time, but recently have become more bothersome.  Patient advised to follow-up with her PCP following hospitalization for repeat evaluation.   OBJECTIVE: BP 160/73  | Pulse 73  | Temp 36.8 °C (Oral)  | Resp 18  | Ht 1.651 m  | Wt 106 kg  | SpO2 93%  | BMI 38.89 kg/m²    Physical Exam Constitutional:      Appearance: She is obese.  HENT:     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal. No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     General: No scleral icterus.       Right eye: No discharge.        Left eye: No discharge.     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No carotid bruit.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard.    Pulmonary:     Comments: Patient has bilateral mild expiratory wheezes without stridor Abdominal:     General: Abdomen is flat. Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Normal range of motion and neck supple.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.