Age: 77.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Legionella test, Leukocytosis, Lung opacity, Malaise, Metabolic function test
Clinical narrative: Hospitalized (9.12.21 - present); COVID-19 positive (9.10.21);  Fully Vaccinated  HISTORY OF PRESENT ILLNESS: Patient is a 78 y.o. male with a past medical history of rheumatoid arthritis on methotrexate, AFib and a flutter on Xarelto, and hypertension who presents today with lightheadedness, weakness and shortness of breath.  The patient states that symptoms started around 9/6.  Symptoms started with a sore throat and developed into a persistent cough.  He has had intermittent episodes of hemoptysis.  He states that he has severe loss of appetite and loss of taste and smell.  He has had difficulty sleeping secondary to his persistent cough.  He has felt weak and lightheaded.  Today he told his wife that he thought he was going to die today.  The patient is previously vaccinated for COVID-19.  He was seen at urgent care on 09/10 where he was officially diagnosed with COVID-19.  He was sent to the ER for evaluation given his hemoptysis.  A CTA thorax was obtained which showed no PE.  Peripheral predominant opacities in the bilateral lungs are nonspecific, but presumed to be related to the patient's diagnosis of Covid 19. Left lower lobe opacities could similarly be related to pneumonia or pulmonary hemorrhage given the history of hemoptysis. Small left pleural effusion.   He was not hypoxic nor tachypneic on exam so he was discharged.  The patient states that he has been increasingly more lightheaded and weak over the past few days prompting his visit today.   In the ER, the patient was tachycardic with a pulse of 131, tachypneic with a respiratory rate of 35 and hypoxic with an SpO2 of 88%.  He was placed on 2 L nasal cannula.  Labs significant for Na 129, AST 70 ALT 51 bilirubin 1.1, hemoglobin 11.6.  CXR 9/12 with left basilar pneumonia.  The patient was given 1 L of IV fluids, Decadron, Tessalon Perles, Tylenol and albuterol. ASSESSMENT / PLAN: Pneumonia due to COVID-19 virus Acute Respiratory Failure with Hypoxia Pleural Effusion, left small Hemoptysis Vaccinated Immunocompromised CXR 9/12 with left basilar pneumonia.  SpO2 in ER 88% on room air, RR 35 CTA Thorax on 9/10 with no PE.  Peripheral predominant opacities in the bilateral lungs are nonspecific, but presumed to be related to the patient's diagnosis of Covid 19. Left lower lobe opacities could similarly be related to pneumonia or pulmonary hemorrhage given the history of hemoptysis. Small left pleural effusion.  Date of symptoms onset: 9/6/21, tested positive 9/10 Symptoms:  Sore throat, fevers, cough, dyspnea, lightheadedness, anorexia, loss of taste and smell, headaches Treatment: Remdesivir (started 9/12), Decadron x 10 days (started 9/12), VTE prophylaxis with the patient's Xarelto, Supplemental Oxygen - wean as able, continuous pulse oximetry and telemetry (given A-fib with RVR in ER), Daily CMP while on Remdesivir, supportive care with PRN anti-tussives, PRN anti-emetics, PRN anti pyretics, IS. -Hold methotrexate -Given hemoptysis and primarily left sided pneumonia - will obtain sputum culture, procalcitonin - consider starting Azithromycin Hyponatremia -NA 129 - s/p 1 L of IVF - re-check in AM - patient has had very poor oral and liquids intake Rheumatoid Arthritis -Hold methotrexate, has not been on prednisone in over a year.   Paroxysmal A-fib History of A-flutter -Continue Cardizem, Metoprolol, Xarelto -On telemetry  Hypertension -Continue Cardizem, Metoprolol and Lisinopril progress note (9.21.21) - still admitted:  Pneumonia due to COVID-19  Acute respiratory failure with hypoxia due to COVID-19 pneumonia Overview CTA on admission without PE, infiltrates consistent with COVID-19 pneumonia.  Steptococcus and legionella urine antigen negative. Procalcitonin negative.  Echocardiogram with normal RV and LV function, negative bubble study. Assessment & Plan Worsening hypoxemia with difficulty recovering after minimal activity led to transfer to MICU 9/15, mild improvement with self-proning - Continue HFNC/NRB mask and self-proning or laying on his side - At significant risk of needing intubation - Added empiric antibiotics--ceftriaxone-- > changed to cefepime 9/20, given length of hospital stay and significant worsening of leukocytosis and Gram-negative rods in sputum  * Pneumonia due to COVID-19 virus Overview 1/11/21, 2/8/21: received COVID-19 vaccine 9/6/21: symptoms developed 9/10/21: diagnosed with COVID-19 9/12/21: admitted to the hospital 9/15/21: transferred to the ICU for desaturation despite 95% high flow NC Assessment & Plan Decadron 6 mg daily (started 9/12/21), will need to decide if course is prolonged past normal 10d Remdesivir (started 9/13/21), completing 9/17 On heparin ggt for atrial fibrillation, and was on xarelto as outpatient.  Changed to lovenox to reduce blood draws This is a 78 y.o. who has a past medical history significant for RA immunosuppressed on Methotrexate, Afib on xarelto, HTN. He was admitted for dyspnea after presenting to the ED 9/12 with symptoms of dyspnea, fatigue and intermittent small hemoptysis since 9/6, had been diagnosed with COVID 9/10 (previously vaccinated). He has since been started on dexamethasone since 9/12 and remdesevir since 9/13 (completed course), initially needing nasal cannula, and later required transfer to the MICU for persistent hypoxia on 9/15 requiring HFNC. Key Plan for Today September 20: --respiratory rate self prone in --problem combination of high-flow nasal cannula oxygen/breather face mask --at high risk for requiring intubation/mechanical ventilation, but does not appear to be required at this time --goal even to negative fluid balance with Lasix (currently 40 mg once daily), severe as tolerated --change ceftriaxone to cefepime, given rising white blood count, worsening chest radiograph --continue full-dose Lovenox for atrial fibrillation and hypercoagulable state of COVID--well --dexamethasone day 9 --advanced diet --patient indicates he would be okay with intubation and mechanical ventilation but would not wish for tracheostomy tube.  Family is supportive this incision. I discussed with patient and also updated his daughter at bedside.  She understands patient is critically ill and is supportive of the plan.  This patient is critically ill and is requiring active support and intensive surveillance to prevent life threatening clinical deterioration.