Age: 52.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Angiogram pulmonary abnormal, Anticoagulant therapy, COVID-19, COVID-19 pneumonia
Clinical narrative: Hospitalized 12/6/2021-still admitted currently; COVID-19 positive 12/6/2021; fully vaccinated   Procedures to be scheduled by PCP: see BW d/c summary   Results/Procedures requiring PCP followup: see BW d/c summary   Admission Date: 12/6/2021 Discharge Date: 12/12/2021 Details of Hospital Stay PRESENTING PROBLEM:  CLL (chronic lymphocytic leukemia) (HCC) [C91.10] Acute respiratory failure with hypoxia (HCC) [J96.01] Acute hypoxemic respiratory failure due to COVID-19 (HCC) [U07.1, J96.01] COVID-19 virus infection [U07.1] Pneumonia due to COVID-19 virus [U07.1, J12.82]  HOSPITAL COURSE: Patient is a 53 y.o. male who presented to the emergency department with complaints of hallucinations and shortness of breath.  Patient has a past medical history of CKD, CLL,  and hyperlipidemia. Patient's pulse oximetry on arrival was 63% upon arrival to the emergency department.  He was subsequently placed on a non-rebreather mask and oxygen saturation increased to 96%.  Additionally, patient was tachycardic and tachypneic.  He had a low-grade fever.  Lab results were significant for hyperleukocytosis, hyperkalemia, and chronic kidney disease.  EKG shows sinus tachycardia.  COVID-19 was positive.  Per report, patient had contracted COVID prior to Thanksgiving.  CTA of the thorax showed no PE, however, there was diffuse bilateral lung opacities present.  Upon assessment, patient was A&O x3, however, he was confused at times about situation.  Suspect presenting symptoms were due to hypoxia related to COVID-19 pneumonia.  Patient has been admitted for further evaluation and management of COVID-19 pneumonia.  On night of 12/8, patient had significant event of decreased responsiveness and confusion. Patient was r/o for acute stroke. CT head, neck and MRI negative for acute ischemic event.  Patient was initially started on lovenox for VTE prophylaxis and USV of left upper extremity showed superficial left cephalic vein thrombus and patient was started on therapeutic lovenox. Within 24 patient had decrease of platelets from 99 to 68 and medication was switched to eliquis for concern for H.I.T.   Patient continued treatment for COVID pneumonia with use of high flo n/c canula. Patient also met sepsis criteria with concern for bacterial pneumonia and was given 5 days of IV zosyn and vancomycin due to positive MRSA screen.   Patient developed severe diarrhea and c-diff testing was ordered but diarrhea stopped prior to collection and no sample was obtained.  Patient had decreased oxygen need but c/o continued cough, chest heaviness, with continued tachycardia and tachypnea. Repeat CT thorax showed extensive right-sided pulmonary embolic burden extending to left side and with mild right heart strain. Hospitalist and PERT team discussed case and it was agreed to transfer patient for probable intervention.  Patient remained in critical but stable condition for transfer.  12/12/2021 Admission Note (transferred to another hospital) -Diagnosed with COVID-19 on 12/6 - symptoms started prior to 11/26.  Treated with Decadron - continue to complete 10 days.  CTA 12/21/21: Interval improvement in moderate patchy ill-defined consolidative and groundglass airspace disease throughout the left greater than right upper lobes, greater than lower lobes -Completed 5 days of Vancomycin and Zosyn 12/6/21-12/11/21 (MRSA screen was positive) for possible bacterial co-infection.  Elevated procalcitonin 1.94. -Requiring Hi-flow at Big Rapids with FIO2 40% - now tolerating the oximizer at 15 L. -Started on therapeutic Lovenox 12/7 for Left Cephalic Vein Thrombus.  Platelets dropped from 99-- >68.  Lovenox stopped with concern for HIT and Eliquis started. -Will start patient on Argatroban with concerns for HIT.  HIT Ab pending.  Hematology consulted -ECHO pending -US lower extremities pending -IR and Pulmonology consulted, planning thrombolysis on 12/13.  NPO at midnight -Telemetry and continuous pulse oximetry -Supportive care with scheduled Mucinex, PRN anti-tussives  Note 12/14/2021: - Patient underwent Bilateral pulmonary angio with right pulmonary thrombectomy on 12/13.  -  2D ECHO prior to thrombectomy showed left ventricular ejection fraction is 52%. The right ventricle is normal size. The right ventricular systolic function is normal. - Currently on IV Argatroban for anticoagulation. Plan to transition to oral NOAC once platelet count normalizes. - Currently requiring 4L O2 via NC. Wean off O2 as able