Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: Blood culture, Blood lactic acid, Bundle branch block right, CHA2DS2-VASc annual stroke risk high, COVID-19
Clinical narrative: Assessment and Plan Patient is a 82 y.o. male patient of CNP with history of CAD s/p multiple stents, type 2 diabetes not on medications, hypertension, and hyperlipidemia who presented to the ED with a chief complaint of upper back pain and probably minimal shortness of breath.  In the ED, the patient was in A. fib with RVR and heart rate 130-150.  The patient was found to have AKI, leukocytosis, and x-ray of the chest showed pneumonia.  He reports that he started to feel sick and tested positive for COVID and influenza A on 11/22/2022.  The patient was started on oseltamivir on that day.   Sepsis Present on admission: yes Etiology: Pneumonia SIRS criteria: Heart rate greater than 90, WBC greater than 12,000, less than 4,000, or greater than 10% bands Evidence of end organ damage: none Initial lactic acid: 1.9 Repeat lactic acid: N/A Current antibiotic regimen: Ceftriaxone and azithromycin Culture data: Blood and urine cultures ordered Vasopressors/steroids: none Initial sepsis checklist:  ? Lactate ordered ??? ? Blood cultures obtained ??? ? Antibiotics initiated ???  ? IV fluids per sepsis protocol ???     Community-acquired pneumonia COVID-19 positive test (U07.1, COVID-19) with Acute Pneumonia (J12.89, Other viral pneumonia) Influenza pneumonia Leukocytosis CBC reviewed, shows leukocytosis XR chest reviewed, showed right mid and lower lobe pneumonia The patient reports positive COVID and influenza a test that were done on 11/22/2022.  Repeat tests here showed positive COVID and negative influenza. The patient was started on Tamiflu once a day.  Increase it to twice a day. Discontinue since influenza is negative Consult ID.   Legionella and strept antigens negative CT chest showed consolidation that needs follow up for clearance. Also multiple pulmonary nodules that need follow up. Ceftriaxone and azithromycin Discharge on cefdinir  Atrial fibrillation with RVR, resolved Hypertension CAD s/p multiple stents The patient presented with A. fib and RVR.  EKG reviewed, shows A. fib and incomplete right bundle branch block. The patient was started on Cardizem drip in the ED and heart rate improved. The patient is on metoprolol tartrate 25 mg twice daily.  Continue this medicine. Suspect the A. fib is due to acute illness and pneumonia. Consult cardiology for new onset A. Fib Heparin drip.  The patient will need anticoagulation due to high CHA2DS2-VASc  score (diabetic, CAD, hypertensive, age 82).  Discharge the patient on Eliquis 5 mg twice daily Cardiology recommended increasing the dose of beta-blockers.  We will switch him to long-acting metoprolol twice daily. Discontinued cardizem drip Outpatient echo as per cardiology recommendation   Type 2 diabetes The patient is not on medications at home Sliding scale insulin while in the hospital   AKI on CKD stage III, improving Creatinine was 1.2 about a month ago BMP reviewed, creatinine on presentation 1.63 The patient is clinically dehydrated.  Started sepsis fluids protocol. Daily BMP   Normocytic anemia No evident blood loss at this time.  Hemoglobin drop after sepsis IV fluids.  Possible dilutional. Continue to monitor If not resolved, outpatient evaluation and management   Pulmonary nodules Outpatient evaluation Will need CT scan to confirm resolution of consolidation