Age: 48.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Nocardiosis, Oxygen saturation decreased, Painful respiration, Peripheral swelling, Pleural effusion
Clinical narrative: BREAKTHROUGH COVID: FULLY VACCINATED COVID POSITIVE REQUIRING 78 HOSPITAL DAYS AND 66 DAYS LONG TERM ACUTE CARE. PT ADMITTED ON 7/31/22 syncopal episode with tachycardia, reports of a heavy period for 37 days, COVID NEGATIVE. Discharged 8/2 .   RE-Admission 8/3 Pt re-tested COVID positive, patient was requiring oxygen therefore she was started on steroids as well as remdesivir id consultation was obtained she is started on DVT prophylaxis Lovenox.  She was continued on heparin drip for her DVTs hypercoagulable workup was obtained and subsequently transition to low-dose Eliquis given her hemoptysis.  Patient was down to 2 L of oxygen. August 31st patient was found to have new left lower lobe pneumonia. September 2nd minocycline was added by ID. Repeat sputum culture revealed R1+ GP cc in 1+ beaded Gram-positive bacilli.  September 5th her Eliquis was decreased to 2.5 mg due to hemoptysis. Bronchoscopy September 7th which revealed left lower lobe with cloudy secretions in washout was performed. Impression was left lower lobe cavity.  With known endobronchial lesions. September 7th were consult was also had an as patient's sputum was growing Aspergillus. Morning of September 8th patient was rapid responded to the ICU for respiratory distress requiring 15% non-rebreather satting in the he is.  A chest x-ray was performed at that point revealing left-sided pneumothorax on the side with bronchoscopy patient was tachycardic tachypneic as well as hypoxic.  An emergent chest tube was placed anteriorly midclavicular line.  Patient also developed hypertension was given 100 mcg phenylephrine x2.  Her respiratory status continue to worsen and she required BiPAP support. She was intubated overnight on 09/17 and started on pressor support. Patient had trach and PEG placed on 10/07. IR placed a femoral port on 10/19 and patient returned to IR on 10/20 for extensive DVT in upper extremity with superior vena cava syndrome for thrombectomy and angioplasty. She was weaned off vent support on 10/30 urinary retention requiring Foley catheter.  11/03/2022 Patient condition was stable and she was transferred to select Specialty Hospital for further medical management 11/4 - Patient awake in bed. Denies shortness of breath, pain or nausea. On T-piece with FiO2 35%. Afebrile. Noted to be tachycardic at times.  11/7 - Patient awake in bed with PMV in place. Denies nausea or painOn T-piece with FiO2 40%. Afebrile. VSS. Labs reviewed and stable. WBC trending down, now 10.5. Surgery consulted to evaluate trach site.   11/8 -  patient desaturating with PMV on and subsequently removed. Afebrile. VSS. Labs reviewed and stable. WBC trending down, now 10.5.  11/9- Patient awake and alert, able to verbalize needs. Patient is on ATC 10 liters/minute FiO2 40%. SpO2 95%. CT neck soft tissue yesterday showed: 1. Tracheostomy catheter in expected position 2. Emphysema with an apparent large bulla in the left lung apex. Chest CT could better evaluate 3. Sphenoid sinusitis 4. Partial opacification of the left mastoid air cells, concerning for inflammatory mastoiditis. Infectious Disease following. Bactrim DS p.o. discontinued and she was started on Merrem and IV vancomycin for sinusitis, mastoiditis and to continue treatment for pulmonary infection with Nocardia cyriacigeorgica. Patient is status post neck wound debridement with Dr. yesterday. Patient passed her FEES now on level 6 regular diet with thin liquids. 11/10- Patient sleeping and arousable to verbal and tactile stimuli , able to verbalize needs. Patient is on ATC 10 liters/minute FiO2 40%. SpO2 96%. CT chest without contrast showed:Emphysematous changes with small blebs on the RIGHT. Multiple large bullae are noted on the LEFT and a LEFT basal bulla demonstrates an air fluid level. LEFT basal infiltrate versus compressive atelectasis.  11/11-  Protonix IV now switched to p.o. pill form.  11/13-  Trach capped, on oxygen supplement 2 liters/minute via nasal cannula, SpO2 98%. 11/14-WBC 11.5, calcium 8.3, AST 59 and alkaline phosphatase 278. Rest of CMP and CBC fairly unremarkable. Foley catheter discontinued and bladder scan per protocol.  11/15- CXR today showed infiltrates in both lower lung zones. Findings are similar to the November 3, 2022 study. Pulmonary following. Patient temperature 96.4°, she is on Merrem IV and vancomycin IV for her sinusitis and mastoiditis. Infectious Disease following. Patient refused Foley catheter removal yesterday. Discussed with patient potential source of infection with use of Foley catheter. Patient agreed and is now amenable for Foley catheter removal. We will do bladder scan q.4 hours per protocol. We will apply purewyck catheter. In no acute distress. 11/16 - On ready/decannulation pathway. Foley catheter removed yesterday; RN reports no need to straight cath; will continue to monitor. Afebrile. VSS. Id following continue on meropenem, vancomycin and voriconazole. 11/17 -Did not sleep well last night; patient reports difficulty urinating which kept her awake. RN reports continued bladder retention; Foley catheter reinserted. Labs reviewed. Potassium 3.4; replace per protocol and repeat level tomorrow. WBC 12.3. Hemoglobin 10.3. Alk phos remains elevated but stable 254. 11/18 - Awake alert, interacting. Her trach is capped, tolerating well, no distress denies shortness of breath. Recent labs reviewed potassium 3.4 patient on antibiotics, remains afebrile, blood pressure stable 11/19-  At 0730 started trach capping w/ nc 2lpm o2, o2sat 96%. Patient able to verbalize needs. 11/120- Patient awake and alert, eating breakfast with noted good appetite. Patient stable on oxygen supplementation 2 liters/minute via nasal cannula, SpO2 95%. Trach is capped. she is currently on Merrem & IV Vancomycin for sinusitis, mastoiditis, & to continue Rx for pulmonary infection with Nocardia cyriacigeorgica.  11/21- Patient noted on Vapotherm trach 21 liters/minute, FiO2 28%, SpO2 96%. Patient awake and alert and able to verbalize needs.  11/22- Patient is stable on oxygen supplementation 2 liters/minute via nasal cannula, SpO2 98% . Trach is capped and she is on decannulation pathway. 11/23- she is off abts, ID following.  11/25- She is participating with her physical therapy. In no acute distress. 11/28-albumin 2.8, alkaline phosphatase 162, hemoglobin 10.7, hematocrit 34, rest of CMP and CBC fairly unremarkable. Patient bilateral upper extremity also noted with slight swelling, we will do ultrasound Doppler bilateral trial extremity to rule out DVT. In no acute distress. 11/29-ultrasound venous Doppler upper extremity,negative. 11/30 -Reports a tightness in her chest that she says she is had for the last 3 months; pain is worsened with deep inspiration but not worsened with activity. CT chest completed shows the large bulla and pneumatoceles in the left lung resolved; persistent COPD with bolus disease; persistent left base infiltrate and effusions.  12/1 -Patient on 2 L nasal cannula. Decannulated.  12/2 - Patient awake in bed. No signs of distress. hypoglycemic 66.  12/3 - Patient awake in bed. No signs of distress. Denies shortness of breath or nausea. Slept well. Patient on 2 L nasal cannula. Xanax changed to p.r.n. per patient request. Afebrile. VSS. Potassium remains low at 3.2; replace per protocol repeat level tomorrow. WBC stable at 9.9. No further episodes of hypoglycemia. Plan to remove Foley Monday. 12/6 - Patient awake in bed. No signs of distress. Reports not feeling well. Says she had low grade fever and cough overnight and did not sleep well. Tmax 99.6. VSS. Patient on 2 L nasal cannula. Foley catheter removed yesterday; RN reports good urine output with no need to straight cath. GI to remove PEG tube today. Discharge planning in progress. 12/7- Patient awake in bed, verbalizes needs. Patient temperature 97.4°, off antibiotics, Infectious Disease following. GI try to remove PEG tube bedside but unable. General surgery consulted for PEG tube removal possibly today. Patient on room air, SpO2 97%. Patient is straight cath x1 this a.m. with urine residual approximately 500 mL. Hytrin dose increase. We are monitoring closely urine output and bladder scan per protocol. In no acute distress at time of evaluation. Discharge planning in progress. 12/8- Patient AAOx3, denies chest pain, shortness O breath, nausea, vomiting, abdominal pain or headache.. Patient temperature 97.2°, off antibiotics, Infectious Disease following. General surgery consulted for endoscopy PEG tube removal today. Patient on oxygen supplementation 2 liters/minute via nasal cannula, SpO2 98%. Patient urinating well, RN staff night shift reports no straight cath procedure done based from bladder scan results. In no acute distress at time evaluation. Labs drawn noted potassium 3.3, we will replace per protocol. Also noted albumin 3.1, hemoglobin 10.6, hematocrit 33.3.. Repeat K level in a.m. 12/9-percutaneous endoscopic gastrostomy tube removal by General surgery yesterday, procedure tolerated well. Patient temperature 98.2°, off antibiotic, Infectious Disease following. Patient denies pain or discomfort. In no acute distress at time of evaluation. 12/10- Patient noted with K 3.1 today we will replace per protocol.  12/11- Repeat lab today showed K 3.4, we will replace per protocol and repeat labs in a.m.  12/12-Noted yesterday KUB constipation, RN staff reports patient moving BM with pastelike consistency. She is already on colace, senokot and Miralax. We will give dulcolax suppository today. Also, CXR left lower lung infiltrate from yesterday.   12/13- Patient awake, alert and oriented x4. She is stable on oxygen supplementation 2 liters/minute via nasal cannula, SpO2 98%. Patient latest temperature 96.8, off antibiotics, Infectious Disease following. Patient states she did moved her BM small amount yesterday but still feels constipated. We will give another Dulcolax suppository today. She is already on Colace, Senokot and MiraLax. Patient denies nausea, vomiting, abdominal pain, shortness at breath, chest pain or headache. In no acute distress discharge planning in progress. 12/14 - KUB completed shows extensive stool in colon; will give tap water enema x1. Denies nausea or shortness of breath. On 2 L nasal cannula. T-max 99.2°. Tachycardic with borderline BP at times. Discharge planning to Rehabilitation in progress. 12/28 - Patient awake in bed. No signs of distress. Noted to be hypotensive this morning with BP of 86/50; 500 mL bolus administered with improvement to 101/64. Patient denies any dizziness or shortness of breath. Received metoprolol and Lasix this morning and became hypotensive again down to 86/54; 2nd 500 mL bolus ordered with improvement. Parameters ordered on Lasix and pain medication. Afebrile. Tachycardic at times. Will continue to monitor BP closely. Routine labs tomorrow. Discharge planning in progress. 12/29 - No further episodes of hypotension overnight or this morning. Afebrile. Tachycardic at times. Hypokalemic with potassium 3.2; replace per protocol    12/30 - Patient reports feeling slightly woozy this morning. RN to hold Lasix and metoprolol. Noted to have fever overnight with T-max 100°. Id ordered urinalysis and chest x-ray and started on meropenem. Tachycardic at times; low 100s during assessment.  12/31- Patient A&O x 3, she is stable on oxygen supplementation 2 liters/minute via nasal cannula, SpO2 99%. Patient urinalysis showed negative UTI. Chest x-ray showed left pleural effusion, left lower lobe associated atelectasis. Findings are worse compared to prior study December 11, 2022. Patient temperature 97.7°, currently on Merrem IV, Infectious Disease following.  1/12Patient sitting in chair. She is stable on oxygen supplementation 2 liters/minute via nasal cannula, SpO2 98%. Patient is afebrile. off antibiotics, Infectious Disease following. She was tachycardic during rounds , 12 lead EKG and cardiology consult was placed. In no acute distress. On PRN pain medication.  1/13 Patient sitting in chair. She is stable on oxygen supplementation 2 liters/minute via nasal cannula. 1/17 Patient awake in bed. Sleeping was ok. Good appetite. Afebrile. Tachycardic at times; on metoprolol and Cardiology following. BP stable. Id following off antibiotics. Discharge planning in progress. D/W cm     Summary Of Imaging 11/3 CXR - left basilar infiltrate with pleural effusion 11/8 CT neck soft tissue: 1. Tracheostomy catheter in expected position  2. Emphysema with an apparent large bulla in the left lung apex. Chest CT could better evaluate  3. Sphenoid sinusitis  4. Partial opacification of the left mastoid air cells, concerning for inflammatory mastoiditis  11/9- CT chest without contrast showed: Emphysematous changes with small blebs on the RIGHT. Multiple large bullae are noted on the LEFT and a LEFT basal bulla demonstrates an air fluid level. LEFT basal infiltrate versus compressive atelectasis.  11/15 CXR - Infiltrates in both lower lung zones. Findings are similar to the November 3, 2022 study.  11/22 CXR- Opacity in the left lower lung, stable.  11/29 CXR There are opacities in the left lung base. This may be due to atelectasis or pneumonia.  11/29 Doppler US BUE - negative for DVT 11/30 CT chest - the large bulla and pneumatoceles in the left lung resolved; persistent COPD with bolus disease; persistent left base infiltrate and effusions 12/11 KUB constipation 12/11 CXR left lower lung infiltrate 12/14 KUB - bowel pattern is normal; no obstruction; extensive stool in colon 12/30 CXR- Chest x-ray showed left pleural effusion, left lower lobe associated atelectasis. Findings are worse compared to prior study December 11, 2022.