Age: 59.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Chest tube insertion, Condition aggravated, Cough, Endotracheal intubation, Fibrin D dimer increased
Clinical narrative: Hospitalized 09/21/2021; COVID-19 positive 09/17/2021; fully vaccinated  Admission note 09/21/2021:    ASSESSMENT Principal Problem:   Pneumonia due to COVID-19 virus   Pertinent Results:   - CT angio thorax Showed 1. Negative for pulmonary embolism.  2. Redemonstration of chronic bilateral pulmonary infiltrates which have pattern that can be seen in the setting of Wegener's granulomatosis. Patient on 6 L nasal cannula without respiratory distress. Procalcitonin elevated at 0.33 Normal white blood cell count Normal lactic acid Mildly elevated AST and ALT; normal bili. Plan:  continue close monitoring and continuous pulse ox; wean oxygen as tolerated to maintain saturations greater than 92%. continue Decadron for total of 10 days. continue remdesivir x5 days.   low threshold to consider coverage for bacterial pneumonia patient worsens clinically or develops productive cough; patient states that his current cough is dry and nonproductive. consider benefit pulm consult tomorrow if patient worsens clinically requires more oxygen support dresser given history of granulomatosis with polyangiitis trend COVID inflammatory labs including a complete blood count, CRP, D-dimer also trend AST and ALT with repeat CMP tomorrow morning  Note from 09/25/2021: Acute hypoxic respiratory failure - stable COVID pneumonia  COVID positive 9/17 w/ symptom onset around 9/10. CT angio thorax consistent with COVID w/ also chronic pulmonary infiltrates seen with GPA, negative for PE. Worsening respiratory status since admission requiring BiPAP and transfer to ICU on 9/22. Now remains stable on HFNC with slightly decreased oxygen reuirements.  -steroids increased to 20 mg for 5 days, then 10 mg for 5 days  - 3 days of azithromycin complete, Day 3/5 of CTX -CRP trending down, DD trending up, will monitor  -low threshold for intubation -Remdesivir ordered -self proning encouraged and patient completing successfully  -MICU on consult, trend COVID labs, lovenox DVT ppx   09/28/2021 note: Worsening respiratory status since admission requiring BiPAP and transfer to ICU on 9/22-23 but he was not intubated and then transferred back to the floor. 3 days of azithromycin complete, 5 days of CTX completed 9/26. Remdesivir completed x5 days 9/25.  Plan: CTA thorax 9/27 demonstrated worsening of bilateral consolidations. Will change steroids to Solu-medrol 30mg BID and add PCP ppx with bactrim D dimer increasing (4k to 12k), will repeat today and if continuing to increase would consider evaluation of upper extremities with dopplers.  self prone as able will obtain ABG now to evaluate patient's oxygenation status, patient currently appears comfortable and is saturating high 90s with high-flow nasal cannula and non-rebreather.  No current need for intubation however patient is very high risk.  Would avoid BiPAP given his pneumomediastinum.   Pneumomediastinum Noted on CTA thorax 9/27. Likely 2/2 COVID/ARDS.  Free air present in the anterior mediastinum and left hilum.  No evidence of esophageal or tracheal perforation on CTA.  Plan: daily CXR, repeat CXR today shows widening of the mediastinum consistent with known pneumomediastinum. no need for antibiotics at this time Additional note on 09/28/2021: Since transfer out of ICU, patient had worsening O2 requirements last night with tachypnea and HFNC 100% FiO2 a/ NRB so was transferred back to the ICU. Since ICU transfer, has been stable and does not appear to be in any respiratory distress. steroids increased to Solumedrol 40 mg q8 hours    Restarted on antibiotics: Vanc/Cefepime for empiric coverage 10/1/2021 note: Since GPA is not likely large contributing factor, will start to wean from steroids starting with 40 mg methylprednisolone BID for 3 days followed by 40 mg daily for 3 days and then will discontinue steroids. Continue PCP ppx with bactrim until off steroids. Continue cefepime through 10/4 for a total of 7 days Encourage patient to self-prone as tolerated Patient continues to require high flow and nonrebreather with 60 L O2 and 100% FiO2. Wean as tolerated with goal of >90% O2 saturation.