Age: 75.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Paralysis, Productive cough, Prone position, Rales, Renal impairment
Clinical narrative: Hospitalized 02/01/2022-still currently admitted; COVID-19 positive 02/01/2022; fully vaccinated plus booster  HISTORY OF PRESENT ILLNESS: This is a 76-year-old male with a past medical history of O2 dependent chronic obstructive pulmonary disease on 2.5 L chronically, CML on Gleevec for at least the last 6 years, pulmonary hypertension, chronic kidney disease stage 3, history of pulmonary embolism in March 2019 for which he is on Eliquis.  Patient presents with 2 week history of cough productive of clear sputum with red streaks, progressive shortness of breath.  He has also had malaise and weakness.  He checked his O2 sats this morning and it was in the 60s, he turned his oxygen up in came to the emergency department for evaluation.  Patient denies any fevers.  He has had diarrhea which is not any different for him since being on Gleevec, several loose stools a day.  He denies any nausea or vomiting.  No loss of taste or smell but states he is just not hungry.   On arrival to the emergency department he was afebrile, blood pressure 113/54, breathing 24 breaths per minute heart rate 103, satting 74% on 2.5 L, now satting 91% on high-flow nasal cannula 60%, 50 L on exam he is ill appearing, conversational dyspnea with frequent wet cough.  Lungs show crackles at the bases bilaterally coarse breath sounds in the mid fields.  Heart was regular rate and rhythm.  Abdomen nontender extremities showed no significant edema   Pneumonia due to COVID-19 virus ASSESSMENT/PLAN:   Acute on chronic hypoxemic respiratory failure secondary to COVID-19 pneumonia -symptom onset greater than 2 weeks, positive test 2 weeks ago per patient -continue supple oxygen up to and including intubation -prednisone 60 mg IV 2 times a day -patient is out of window for remdesivir due to symptom duration -daily labs including CMP, complete blood count with diff, CRP, D-dimer -incentive spirometry, deep breathing -pronation as tolerated -patient is on Gleevec, therefore immunosuppressed -will start antibiotics with Zosyn and vancomycin -check MRSA screen -patient is on Eliquis for VTE, given his acute illness, I will change it to a heparin drip tonight given we may have to perform procedures -Pepcid for GI prophylaxis 02/05/2022 notes: ASSESSMENT / PLAN: * Pneumonia due to COVID-19 virus Assessment & Plan Patient deteriorated to respiratory failure and was endotracheally intubated and placed on mechanical ventilation this morning.  General surgery was consulted and kindly placed a triple-lumen central venous catheter and arterial line.  Patient symptom onset greater than 2 weeks.  Day 1 of mechanical ventilation.  Patient on day 4/7 piperacillin tazobactam.   Continue steroid therapy with Solu-Medrol will increase dose to 60 mg q.12 hours due to worsening respiratory status.   Maintain negative fluid balance with Lasix 40 mg IV 2 times a day. Patient paralyzed(Day 1) and proned. Monitor ABGs q.4 hours.   Daily chest x-ray. Resume unfractionated heparin therapy.  Convert to Lovenox tonight.    Consulted VICU for support and recommendations.  Appreciate their input. Acute on chronic respiratory failure with hypoxemia (HCC) Assessment & Plan Patient required increase in his oxygen therapy to 100% by high-flow nasal cannula and had persistent hypoxemia on ABG so was endotracheally intubated and placed on the mechanical ventilator.   02/08/2022 notes: Assessment and Plan Acute on chronic respiratory failure with hypoxemia (HCC) Assessment & Plan Secondary to COVID-19 viral pneumonia on background of COPD/emphysema with chronic hypoxic respiratory failure (baseline 2.5 LPM) Admitted 2/1 Initially treated with HFNC, then intubated 2/5   Current support: FIO2 (%): 40 %  Sedation: Deeply sedated, with NMB   - Continue with lung protective ventilatory strategy - Wean FiO2 and PEEP as able, goal PaO2 55-80 and SpO2 88-95% - Continue with deep sedation, goal RASS -5, and NMB for now - Continue with prone positioning as long as FiO2 needs </= 60% and P/F ratio <150 - Avoid hypervolemia as possible, goal even to slightly positive fluid balance given renal dysfunction - Continue empiric zosyn, to complete 7 days of abx tx today (infectious studies thus far NGTD)  * Pneumonia due to COVID-19 virus Assessment & Plan - Continue steroids for COVID related pneumonitis; will need 10 days minimum of steroid tx - Fluid balance as above - Therapeutic anticoagulation as below - Otherwise, management of acute hypoxic respiratory failure as above