Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Pleural effusion, Pneumonia, Procalcitonin increased, Protein total normal, Pyrexia
Clinical narrative: Hospitalized (12.9.21 - 12.12.21); COVID-19 positive (12.9.21); Fully vaccinated -moderna x2  H&P: CHIEF COMPLAINT: COVID-19   Assessment/Plan    ASSESSMENT/PLAN: * COVID-19 Assessment & Plan Date of Symptom onset: 12/1/21 Date of positive COVID-19 test: 12/9/21 CXR: Patchy perihilar opacities and interstitial prominence which can be seen with pulmonary edema and/or potential atypical infection in the correct clinical setting. Blunting of costophrenic angles potentially related atelectasis and/or small pleural effusions.    Current oxygen requirement: SpO2: 97 % O2 Flow Rate (l/min): 2 l/min   CRP: No results found for requested labs within last 720 hours.  D-dimer: No results found for requested labs within last 720 hours.. Ferritin: ordered and pending    Prone patient as tolerated Albuterol INH 2 puffs q 4 hours Dexamethasone - 6 mg PO day 1/10 Due to AKI, patient does not qualify for Remdesivir  DVT prophylaxis: Lovenox, SCDs Daily CBC w/diff, CMP, CRP, D-Dimer   Sepsis  Assessment & Plan Sepsis secondary to covid-19 pneumonia   2/4 SIRS (tachycardia, tachypnea) with AKI requiring 2L nasal cannula   Continue 0.9% sodium chloride @ 125 ml/hr Blood cultures x2 pending Lactic acid 1.6 in ER Pro-cal ordered and pending    AKI (acute kidney injury)  Assessment & Plan Likely secondary to poor oral intake/dehydration Baseline creatinine: 0.83 Current Creatinine 2.42   UA ordered and pending IVF 0.9% NS @ 125 ml/hr Avoid nephrotoxins & NSAIDs, ACE-I/ARBs, IV Contrasts Strict Intake and Output CMP in am   Acute respiratory failure with hypoxia  Assessment & Plan Secondary to COVID-19 Baseline RA at home Currently on 2L Nasal Cannula Maintain O2 sat 90% or >  Wean oxygen as tolerated Bronchopulmonary protocol  Encourage pulmonary toileting Continuous Pulse Ox    Essential hypertension, benign Assessment & Plan Resume home metoprolol succinate xl 100 mg PO q AM   Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin Assessment & Plan Lab Results Component Value Date   HGBA1C 6.6 (H) 04/17/2021     Repeat A1c pending Hold home oral oral agents Low dose sliding scale insulin  ACHS   Class 3 severe obesity due to excess calories with serious comorbidity and body mass index (BMI) of 45.0 to 49.9 in adult  Assessment & Plan BMI 45.55 on 12/9/21 Encourage diet and exercise as appropriate           Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 66 y.o. female who presents today with shortness of breath.  Patient is vaccinated for COVID-19.   Patient presents to the ER today due to worsening shortness of breath and cough.  Symptoms started at the beginning of December with lack of energy, decreased appetite, cough, runny nose.  Symptoms gradually progressed to worsening cough with sputum production, shortness of breath, orthopnea.  Patient denies recent sick contacts.  She states she was vaccinated for COVID-19 in March.  Patient states that over the last week she has not been able to eat due to lack of appetite and that she has been unable to lay flat due to shortness of breath and worsening cough.  Today symptoms became intolerable so she decided to seek further care in the ER.   While in ER patient tested positive for COVID-19.  Vitals were remarkable for temperature 100.1°, heart rate 116, respiratory rate 22, and oxygen saturation 89% on room air.  Patient was placed on 2 L nasal cannula and oxygen saturation increased to 97%.  Patient lab values were remarkable for sodium 134, BUN 59, creatinine 2.42, BNP 930. EKG was obtained in ER which revealed a sinus tachycardia heart rate 113. Chest x-ray was obtained while the patient was in ER which was notable for "patchy perihilar opacities and interstitial prominence which can be seen with pulmonary edema and or potential atypical infection in the correct clinical setting.  No evidence of pneumothorax.  Blunting of the costophrenic angles potentially related atelectasis and/or small pleural effusions." Hospitalist was asked to admit patient for management of COVID-19 and AKI.   Patient seen and examined in the ER.  She does not appear to be in emotional distress.  She does appear tachypneic, diaphoretic, and ill appearing.  She is currently on 2 L nasal cannula.  She has audible rhonchi and wheezing.  Strong a congested cough is noted during exam.  At this time she does endorse subjective fevers, decreased appetite, shortness of breath at rest and with activity, orthopnea, cough with rusty colored sputum production.  She denies dizziness or lightheadedness, chest pain, palpitations, nausea, vomiting, diarrhea.  At this time we will admit the patient for management of COVID-19 with steroids, oxygen support, breathing treatments, pulmonary toileting, and encourage prone positioning as patient tolerates.  Unfortunately due to patient's AKI patient is not a candidate for remdesivir treatment at this time.  Plan of care was discussed with the patient at the bedside.  She is agreeable to the plan of care.  Questions answered to patient's satisfaction.   I discussed with the patient that COVID-19 illness trajectory can be unpredictable and may require escalating oxygen therapy which includes but is not limited to oxygen nasal cannula, oxygen via facemask such as non-rebreather, high-flow nasal cannula, BiPAP/CPAP, or endotracheal intubation with mechanical ventilation.  Patient is agreeable to to these interventions if necessary.   Code status was discussed with the patient at the bedside.  Patient wishes to be a full code. Patient Active Problem List Diagnosis ? Class 3 severe obesity due to excess calories with serious comorbidity and body mass index (BMI) of 45.0 to 49.9 in adult ? Essential hypertension, benign ? Decreased pulses in feet ? Lightheadedness ? Hyperkalemia ? Mild intermittent asthma with acute exacerbation ? Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin  ? COVID-19 ? Acute respiratory failure with hypoxia  ? AKI (acute kidney injury)  ? Sepsis      Past medical, surgical, family and social history reviewed.     Prescriptions Prior to Admission (Not in a hospital admission)   No Known Allergies Review of Systems Constitutional:  Positive for activity change, appetite change, diaphoresis, fatigue and fever.  Respiratory:  Positive for cough, wheezing, shortness of breath and sputum production.   Cardiovascular:  Positive for orthopnea. Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Negative.  Musculoskeletal:  Negative.  Neurological:  Negative for headaches, dizziness, light-headedness, tremors, numbness/tingling and weakness.  See HPI for pertinent positives and negatives, all other systems reviewed and are negative.         Objective    OBJECTIVE: BP 120/58  | Pulse 116  | Temp 100.1 °F (37.8 °C) (Oral)  | Resp 22  | Ht 1.676 m (5' 6")  | Wt 128 kg (282 lb 3 oz)  | SpO2 97%  | BMI 45.55 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: She is obese. She is ill-appearing, toxic-appearing and diaphoretic.     Interventions: Nasal cannula in place.  HENT:     Head: Normocephalic.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Tachypnea present. No accessory muscle usage or respiratory distress.     Breath sounds: Wheezing, rhonchi and rales present.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Skin:    General: Skin is warm.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.     GCS: GCS eye subscore is 4. GCS verbal subscore is 5. GCS motor subscore is 6.  Psychiatric:        Speech: Speech normal.        Behavior: Behavior is cooperative.    12/11/2021 progress note: PROGRESS NOTE   CHIEF COMPLAINT COVID-19   Assessment/Plan    ASSESSMENT / PLAN * COVID-19 Assessment & Plan Improved.  On room air..  Date of Symptom onset: 12/1/21  CXR: Patchy perihilar opacities and interstitial prominence, bilateral small pleural effusions.  -Dexamethasone 6 mg day 4 -CT angiogram negative for pulmonary embolism. -remdesivir held due to AKI -prophylactic dose enoxaparin -concurrent treatment for community-acquired pneumonia with ceftriaxone/azithromycin   Community acquired pneumonia Assessment & Plan Elevated procalcitonin, bilateral bronchopneumonia on CT.          -continue ceftriaxone azithromycin          -discharge on oral antibiotic to complete 5 days therapy   AKI (acute kidney injury)  Assessment & Plan Improving.  Baseline creatinine: 0.83, admission 2.42.          -renally dose medications          -no NSAIDs   Class 3 severe obesity due to excess calories with serious comorbidity and body mass index (BMI) of 45.0 to 49.9 in adult  Assessment & Plan BMI 45.55 on 12/9/21          -increased morbidity and mortality given COVID-19    Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin Assessment & l          -insulin sliding scale   Essential hypertension, benign Assessment & Plan          -metoprolol succinate 100 mg q.a.m.       Subjective    SUBJECTIVE   LOS 2 Much improved.  Patient on room air and comfortable.  No acute distress.  Patient feels well.  Plan on observation overnight prior to discharge     Objective    OBJECTIVE   BP 102/82  | Pulse 69  | Temp 36.3 °C (Oral)  | Resp 20  | Ht 1.676 m  | Wt 124.6 kg  | SpO2 97%  | BMI 44.32 kg/m²      Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is well-developed.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard. No friction rub. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no rebound.  Musculoskeletal:        General: No deformity. Normal range of motion.     Cervical back: Normal range of motion.  Skin:    Findings: No rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.