Age: 61.0
Sex: M
Vaccine: COVID19
Symptoms: Bilevel positive airway pressure, Blood beta-D-glucan, Blood bicarbonate normal, Blood creatinine increased, Blood culture
Clinical narrative: Patient received second dose of COVID vaccine on 3/31/2021, tested positive for COVID on 8/14/21.  8/14/21: History Of Present Illness Patient is a 61 y.o. male with a PMH of depression, insomnia, GERD, hypothyroidism, COPD, OSA on BiPAP at bedtime, DMII, HTN, HLD, CAD s/p PCI with stents x 6 (last 8/2021), and metastatic colon cancer on chemotherapy presents to ED with dyspnea.  Pt reports having a cough and congestion that started last Thursday (8/5).  Pt reports feeling more fatigue as well which he thought was related to cycle 2 of FOLFIRI that he just completed.  Pt was evaluated by his PCP on 8/5 and started on cough medicine with Cefdinir.  Pt was not tested for COVID19 at that time.  Pt reports his symptoms became progressively worse with dyspnea even at rest over the last 3 days.  Pt reports he has been checking his SpO2 at home with saturations as low as 81% on room air yesterday.  Pt reports fever at night as high as 102.  Pt denies nausea, vomiting, diarrhea, abdominal pain, dysuria, sore throat, chest pain, heart palpitations, travel, or known sick contacts.  Pt received the COVID19 vaccine a few months ago.  On presentation to the ED, pt with SpO2 in the low 80's. Pt was placed on 6L nasal cannula with slight improvement with SpO2 88-90%.  Pt then placed on his home BiPAP that he wear at night with improvement of his SpO2.  Pt then weaned back down to 4L nasal cannula with SpO2 90% on admission.  CXR shows patchy opacities in both lungs that could be edema pneumonia and atypical infection.  COVID19 was positive. IM consulted for admission.   Assessment and plan: 61 y.o. male with a PMH of depression, insomnia, GERD, hypothyroidism, COPD, OSA on BiPAP at bedtime, DMII, HTN, HLD, CAD s/p PCI with stents x 6 (last 8/2021), and metastatic colon cancer on chemotherapy presents to ED with dyspnea.  Pt reports having a cough and congestion that started last Thursday (8/5).  Pt reports feeling more fatigue as well which he thought was related to cycle 2 of FOLFIRI that he just completed.  Pt was evaluated by his PCP on 8/5 and started on cough medicine with Cefdinir.  Pt was not tested for COVID19 at that time.  Pt reports his symptoms became progressively worse with dyspnea even at rest over the last 3 days.  Pt reports he has been checking his SpO2 at home with saturations as low as 81% on room air yesterday.  Pt reports fever at night as high as 102.  Pt denies nausea, vomiting, diarrhea, abdominal pain, dysuria, sore throat, chest pain, heart palpitations, travel, or known sick contacts.  Pt received the COVID19 vaccine a few months ago.       Acute Hypoxic Respiratory Failure likely 2/2 COVID19 in Immunocompromised with Neutropenia  Obstructive Sleep Apnea  ?COPD  -On presentation to the ED, pt with SpO2 in the low 80's. Pt was placed on 6L nasal cannula with slight improvement with SpO2 88-90%.  Pt then placed on his home BiPAP that he wear at night with improvement of his SpO2.  Pt then weaned back down to 4L nasal cannula with SpO2 90% on admission.   Wife placing pt back on BiPAP with home setting for the night -pH 7.4, PCO2 36, PO2 50, and HCO3 22 -WBC 2118 with ANC 1590 -Troponin 18--- >19 -EKG without acute ST changes  -COVID 19 positive on 8/13/21 -BNP, procal, LDH, CRP, d dimer, and ferritin pending  -CBC with diff, ferritin, LDH, d dimer, and CRP daily with AM labs  -Pt given Vanc and Cefepime in the ED, will hold further antibiotics for now.  Strep pneumo, legionella, and blood cx pending  -Pt started on Decadron 6mg daily and Remdesivir per protocol -Titrate O2 to maintain SpO2 > 95% -MDI with spacer given COVID PRN  -Airborne, contact and eye protection precautions   Metastatic Colon Cancer on Chemotherapy -Follows with Oncology  -s/p colectomy then end ileostomy  -s/p 6 cycles FOLFOX -PET in June with liver and poss mediastinal node  -Started on FOLFIRI with bevacizumab added Cycle #2 on 8/3/21 (with plans for ECHO Q3 months) -Consult Oncology as needed    Pancytopenia  -Hgb 11.0, Platelets 153K, and WBC 2118 with ANC 1590 -Etiology likely 2/2 chemotherapy  -Continue to trend, transfuse Hgb < 7 and platelets < 10,000   Acute Kidney Injury  -sCr 1.37, baseline ~1.0 to 1.1 -UA pending  -Avoid NSAID/Nephrotoxin -Renal dose medications -Strict I&O -Repeat BMP in the AM    Type II Diabetes with Hyperglycemia -Glucose was 123 on admission  -Pt on Metformin and Victoza at home  -FSBS AC/HS with correctional insulin -Consistent carb diet      CAD  -s/p cardiac stents x 6, last 2 placed in 2020 -ECHO 8/2021 with EF 50-60% -Resume home ASA, Plavix, and statin -Will hold home Losartan in setting of AKI, resume as appropriate -Will resume home Bisoprolol for now  -Resume home Spironolactone    Hypertension  -SBP 100's on admission -Will hold home Losartan in setting of AKI, resume as appropriate -Will resume home Bisoprolol for now    Obesity  -BMI 36.96 -Complicates all aspects of care  9/3/21: Discharge Summary Hospitalization Admit Date/Time: 8/13/2021  9:57 PM Admitting Attending:  Discharge Date: 9/3/21 Discharge Attending Physician: Md  Referring provider name and address:  No referring provider defined for this encounter.   Chief Concern, Brief History of Present Illness, and Hospital Course Patient is a 61 y.o. male with a PMH of depression, insomnia, GERD, hypothyroidism, COPD, OSA on BiPAP at bedtime, DMII, HTN, HLD, CAD s/p PCI with stents x 6 (last 8/2021) at CB, Familial Hydrocalcicuric Hypercalcemia and metastatic colon cancer on chemotherapy presents to UK ED with dyspnea on 8/13, found to be COVID + 8/14.  Per chart review, patient called his medical oncologist with worsening respiratory symptoms and he was advised to come to ER for workup for fever and possible COVID symptoms. Of note, patient did receive Pfizer COVID Vaccine [3/6, 3/31]. Patient thought his increasing fatigue and weakness was related to cycle 2 of FOLFIRI that he just completed.     On presentation to the ED on 8/13, pt with SpO2 in the low 80's. Pt was placed on 6L nasal cannula with slight improvement with SpO2 88-90%.  Pt then placed on his home BiPAP that he wear at night with improvement of his SpO2. CT PE remarkable for GGO and consolidations most consistent with multifocal infection. During the afternoon of 8/14, MICU was consulted for increasing oxygenation requirements. On examination patient is on HFNC  40L/60% with a nonrebreather. Sats 88-91%. Increased work of breathing appreciated. Admitted to MICU for further management and evaluation.   After admission to ICU, he remained on HFNC.  He was diuresed and started on broad spectrum antibiotics with Vanc and Cefepime and dexamethasone 6mg.  On 8/17, he had a hypoxic event after coughing, and was placed on 100% BiPAP with improvement in hypoxia.  However, later  in the afternoon on 8/17, he was intubated for hypoxia.  He was started on low dose vasopressors after intubation and increased to dexa/ARDS.  He completed 7-day course of empiric Cefepime for secondary bacterial PNA on 8/20.  He completed dexa/ARDS on 8/26.  He has been intermittently diuresed.  He was proned on 8/25 due to severe ARDS and decreased PF ratio.  He was supined on 8/27.   On 8/28, he spiked a fever and had worsened leukocytosis (from 15k to 40k) along with shock.  He was re-cultured and started on empiric broad-spectrum Vanc and Zosyn.  He had increased ileostomy output at that time, therefore C. Diff sample was obtained, however was negative.  Levophed drip was started for septic shock.  He has had persistent fever despite Tylenol and worsening leukocytosis and without source, therefore venous duplex and beta glucan and fungal serologies obtained on 8/29.    RESOLVED ISSUES:   Pancytopenia (POA) (Resolved) - Etiology likely due to chemotherapy  - Continue to trend, transfuse Hgb < 7 and platelets < 10,000   Given severity of patient's respiratory failure/ARDS secondary to COVID-19 pneumonia he will be unable to receive any chemotherapy for the foreseeable future.  Heme Onc was consulted and without chemotherapy his aggressive metastatic colon cancer will likely cause him to pass away.  Extensive discussions with his wife and she wishes to make him comfortable and terminally extubate with our inpatient hospice team. Time of Death: 9/3/21 10:52pm