Age: 86.0
Sex: F
Vaccine: COVID19
Symptoms: Anion gap, Anticoagulant therapy, Anticoagulation drug level increased, Aspartate aminotransferase normal, Asthenia
Clinical narrative: Hospitalized (1.16.22 - still admitted currently); COVID-19 positive (1.16.22-PCR vs 1.13.22-at outside facility/reported); Fully vaccinated -moderna x2 1/16/22 H&P:History and Physical.HOSPITALIST                                              Chief complaint Shortness of breath History of Present Illness Patient is a 86 y.o female who is on 2 L of oxygen at baseline presents with 10 days of worsening shortness of breath, chest tightness, fever, generalized weakness.  She is here today with her granddaughter who is also her caregiver. She went to another Hospital 3 days ago was diagnosed with COVID received monoclonal antibodies and diagnosed with pulmonary emboli started on Eliquis.  She was told to stop her aspirin and Plavix.  She did not receive her COVID booster.  She has had progressively worsening shortness of breath and weakness at home.  Her granddaughter checked her oxygen and found it to be in the 70s.  She was having a difficult time getting around the house with her walker. EMS was called and started her on 6 L oxygen and brought her to the emergency department.   She is feeling a little better on the high-flow nasal cannula.  But continues to feel weak.  She has not had a bowel movement in multiple days because she has not been eating.     In the emergency department she received albuterol 8 puffs, COVID positive, CT angiogram thorax showed pulmonary embolism and started on heparin drip.  Bilateral lower extremity ultrasound ordered.  She was placed on high-flow for which she had a improvement. Review of Systems Constitutional:  Positive for activity change, fatigue and fever. Negative for chills.  HENT: Positive for hearing loss. Negative for congestion, rhinorrhea and sneezing.  Eyes: Negative for eye discharge and visual disturbance.  Respiratory:  Positive for cough, wheezing, shortness of breath and chest tightness. Negative for sputum production.   Cardiovascular:  Positive for claudication and leg swelling. Negative for chest pain and palpitations.  Gastrointestinal:  Positive for constipation. Negative for nausea, vomiting, abdominal pain and diarrhea.  Genitourinary:  Negative for difficulty urinating and dysuria.  Musculoskeletal:  Positive for edema. Negative for joint pain and muscle pain.  Neurological:  Positive for tremors and weakness. Negative for loss of consciousness.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Skin:  Negative for rash.    Objective BP 118/58  | Pulse 111  | Temp 37.5 °C  | Resp 22  | Wt 55.3 kg  | SpO2 93%  | BMI 21.94 kg/m²  FIO2 (%): 45 % Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is well-developed. She is ill-appearing.     Comments: Sitting in bed Hard of hearing  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Comments: High-flow nasal cannula in place    Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: No oropharyngeal exudate or posterior oropharyngeal erythema.     Comments: No teeth Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Tachycardia present.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard.    Pulmonary:     Effort: Respiratory distress present.     Breath sounds: Wheezing present.     Comments: Coarse breath sounds bilaterally Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion.     Right lower leg: Edema present.     Left lower leg: Edema present.     Comments: Due to post-polio syndrome right lower extremity is weak so there is no strength for plantar flexion or dorsal flexion.  She has chronic 1+ lower extremity edema which her granddaughter says is stable.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.  Assessment and Plan   COVID 19  Acute on chronic Hypoxic Respiratory Failure Sepsis on admission Pulmonary embolism Partial Vaccination, missed booster due 12/2021 Presenting symptoms:  Weakness, fever, body aches, shortness of breath. SIRS 2 criteria met: HR 109, RR 22, TEMP 37.9, WBC 6.4 COVID 19 detected by PCR: 01/16/2022. Symptomatic day: 10 Received monoclonal antibodies 01/13/2022 Received heparin infusion, ibuprofen, Decadron 6 mg, albuterol in ED. Current oxygen saturation 94%, oxygen requirement 2 L baseline on high flow currently Severe Respiratory isolation Dexamethasone 6 mg oral daily 1/10 days. Remdesivir not appropriate as she is out of the window. Will need daily CMP monitoring for liver and renal toxicities. Daily labs CBC with differential, CMP, CRP, D-dimer  Continuous pulse oximetry and telemetry  Heparin infusion for pulmonary embolism, was started on Eliquis 01/13/2022 when at other hospital, heparin started in the ED so continued Awaiting lower extremity ultrasound   Chronic obstructive pulmonary disease Chronic systemic steroid use Nicotine dependence in remission I do not think she is in exacerbation.  Will order home Trelegy as non formulary as they brought it.  Will also order albuterol inhaler 2 puffs every 6 hours as needed for shortness of breath.  She receives prednisone 6 mg daily which will be replaced with Decadron 6 mg as noted above.   Primary hypertension Mixed hyperlipidemia Tachycardia Patient and granddaughter both state that she was started on metoprolol tartrate 50 mg 2 times a day for tachycardia not blood pressure control.  They denied diagnosis of atrial fibrillation.  I can see in outpatient notes that it is related to blood pressure so it will be continued at this dose. Continue atorvastatin 20 mg daily   Anemia Hemoglobin 11.0 MCV 96.2 No signs of bleeding continue to monitor   Adenocarcinoma of left upper lung post radiation treatment 05/2019 Pulmonary nodule Opacities Noted on CTA irregular shaped pulmonary nodule within the subpleural region of the left upper lobe measuring 12 x 9 mm 1st 10 x 8 mm previously, ground-glass pulmonary nodules bilateral upper lobes recommending follow-up imaging. Follows with pulmonology.   Mediastinal lymph node Noted on CTA mildly enlarged mediastinal lymph node 12 mm versus 10 mm previously Follows with pulmonology.   Post-polio syndrome Lower extremity edema She typically wears compression stockings and takes Lasix 20 mg daily. Right lower extremity weakness, unchanged.   Abdominal aortic aneurysm Asymptomatic bilateral carotid artery stenosis Peripheral vascular disease with intermittent claudication Noted.  See Database.   GERD Continue home Protonix 40 mg daily   Diet:  General GI Prophylaxis:  Protonix Code Status:  Do not resuscitate, no blood transfusions PT/OT:  Ordered Disposition:  Pending respiratory improvement  1/24/22 General Medicine progress note:  signed by MD at 1/24/2022  3:23 PM Hospitalist Note:    I saw and examined the patient today and read and verified the details of the resident/fellow's note.  I agree with the assessment and plan, which I discussed and supervised. Patient is a 86 y.o. old female with PMHx of COPD on home 2L, HTN, adenocarcinoma of the left upper lung, who is here with acute on chronic hypoxic respiratory failure secondary to COVID-19 pneumonia, complicated by PE. Patient back to her home O2.     Physical Examination:  General:  Alert and oriented.   Respiratory:  Lungs with bilateral crackles, , Respirations are non-labored.   Cardiovascular:  Normal rate, Regular rhythm.   Gastrointestinal:  Soft, Non-distended, non-tender to palpation Musculoskeletal:  No edema in the LE bilaterally Integumentary:  Warm, No pallor.   Psychiatric:  Cooperative. Neuro: alert and oriented x 3, no focal deficits on exam       MDM: Continue treatment for her COVID-19 pneumonia, and PE. Discharge to SAR when placement available.  Progress Note. HOSPITALIST  Chief complaint Acute hypoxemic respiratory failure due to COVID-19   Chief Complaint Patient presents with ? SHORTNESS OF BREATH     per ems reports that pt was seen and treated for covid at other hospital on wednesday was given monoclonal antibodies and sent home. ems reprts that since friday pt was increased weakness and shortness of breath. today family called ems due to increased cough,and shortness of breath with oxygen levels in the 80's on 2 liters of oxygen.  Subjective LOS: 8 Sitting up in bed, eating breakfast and taking morning meds. Still feeling dyspneic with movement, but she feels this is slowly improving. Felt good to get a shower and washed up over the wknd.   Review of Systems Constitutional:  Negative for chills and fever.  HENT: Negative for sore throat.  Respiratory:  Positive for cough and shortness of breath (slightly improved).   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Negative for dysuria.  Neurological:  Positive for weakness. Negative for headaches, dizziness, light-headedness and numbness/tingling.  Physical Exam BP 144/72  | Pulse 77  | Temp 36.8 °C (Oral)  | Resp 20  | Ht 1.626 m  | Wt 53.4 kg  | SpO2 93%  | BMI 20.21 kg/m²  FIO2 (%): 45 %  No intake or output data in the 24 hours ending 01/24/22 0810   Physical Exam Vitals reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is ill-appearing. She is not toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: No posterior oropharyngeal erythema.  Eyes:     General: No scleral icterus.       Right eye: No discharge.        Left eye: No discharge.     Extraocular Movements: Extraocular movements intact.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Rales (bibasilar) present. No wheezing.     Comments: Poor air movement overall. Coughing with deep breaths. Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: No tenderness or signs of injury. Normal range of motion.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: She is alert. Mental status is at baseline.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.  Assessment/Plan   COVID 19  Acute on chronic Hypoxic Respiratory Failure, resolved Sepsis on admission, resolved Pulmonary embolism Partial Vaccination, missed booster due 12/2021 Presenting symptoms:  Weakness, fever, body aches, shortness of breath. SIRS 2 criteria met: HR 109, RR 22, TEMP 37.9, WBC 6.4 COVID 19 detected by PCR: 01/16/2022. Symptomatic onset 1/16/22. CTA with acute PE and right upper lobe, no evidence of right heart strain; first identified on 1/13 at other ED; started on Eliquis and sent home. No DVT on lower extremity Dopplers here. Received monoclonal antibodies 01/13. Received heparin infusion, ibuprofen, Decadron 6 mg, albuterol in ED. Current oxygen saturation 94%, oxygen requirement 2 L baseline and she is back to baseline now -Continue Dexamethasone 6 mg oral daily (day 9/10) Continuous pulse oximetry Heparin infusion for pulmonary embolism, was started on Eliquis 01/13/2022 when at other hospital, heparin started in the ED so continued at admission -heparin level elevated so heparin was stopped and she was restarted on Eliquis              -Eliquis 5 mg 2 times a day to be continued at discharge -daily labs discontinued    Chronic obstructive pulmonary disease Chronic systemic steroid use Nicotine dependence in remission Does not appear to be in exacerbation.    -home Trelegy -continue albuterol inhaler 2 puffs every 6 hours as needed for shortness of breath.  -She receives prednisone 6 mg daily which will be replaced with Decadron 6 mg as noted above.   Primary hypertension Mixed hyperlipidemia Tachycardia Patient and granddaughter both state that she was started on metoprolol tartrate 50 mg 2 times a day. -continue metoprolol -Continue atorvastatin   Anemia Admission Hemoglobin 11.0 MCV 96.2, stable No signs of bleeding, continue to monitor   Adenocarcinoma of left upper lung post radiation treatment 05/2019 Pulmonary nodule Opacities Noted on CTA irregular shaped pulmonary nodule within the subpleural region of the left upper lobe measuring 12 x 9 mm 1st 10 x 8 mm previously, ground-glass pulmonary nodules bilateral upper lobes recommending follow-up imaging. Follows with pulmonology.   Mediastinal lymph node Noted on CTA mildly enlarged mediastinal lymph node 12 mm versus 10 mm previously Follows with pulmonology.   Post-polio syndrome Lower extremity edema She typically wears compression stockings and takes Lasix 20 mg daily. Right lower extremity weakness, unchanged.   Abdominal aortic aneurysm Asymptomatic bilateral carotid artery stenosis Peripheral vascular disease with intermittent claudication Noted.  See Database.   GERD Continue home Protonix 40 mg daily   Diet:  General GI Prophylaxis:  Protonix Code Status:  Do not resuscitate, no blood transfusions PT/OT:  Ordered Disposition:  Back to baseline o2 2L NC since 1/20/22. Still feeling SOB with exertion. Awaiting placement, care management involved.