Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Blood cortisol, Blood lactic acid, Blood thyroid stimulating hormone decreased, Brain natriuretic peptide increased, COVID-19
Clinical narrative: The patient is a 72 y female with a history of AFIB presenting to the ED accompanied by her daughter with complaints of shortness of breath. Per the daughter, the patient was in the facility January 28 th for Covid-19 pneumonia and paracardial tamponade and was hospitalized for two months. She underwent a paracardial window. The patient received a CTA Chest on 3/6 showing no evidence of pulmonary embolism. Bilateral diffuse ground-glass opacities throughout the lungs with superimposed patchy alveolar airspace disease in the right upper lobe and right lower lobe.There has been improved aeration within the upper lobes and left lower lobe.These infiltrates likely sequelae of Covid pneumonia. Resolution of pleural effusions. She was discharged to facility and presents today to the facility with complaints of shortness of breath and increased heart rate. She also repots chest pain. The daughter verbalizes at facility, the patient "went limp" while attempting to get up for rehab, adding this has happened multiple times. Per the patients daughter, the patients anxiety has been "out of control". Per the daughter, her mother does have a history of AFIB for which she takes Eliquis. The patient denies use of antibiotics currently. She further denies abdominal pain. he patient does verify that she is a full code. There are no further complaints at this time.     Patient's pertinent past medical, social, family medical history were reviewed from both the nursing notes and the electronic medical record.  The patient was seen and examined. Prior to arrival in the facility, the patient received breathing treatment and 125 Solumedrol. The patient's SPO2 was 92% on room air so she was placed on 6 L via nasal cannula. Upon arrival, the patient was tachycardic at 109 and tachypneac at 22. Workup was initiated including an EKG, multiple laboratory studies and a chest x-ray. An IV was established and the patient was given a 0.5 L NS bolus to be continued at 125 mL/hr.   He was given an additional Duo neb breathing treatment.    EKG shows AFib with a rate of 109 beats per minute.  No acute ST changes.     CMP is essentially normal. Lactic acid is normal at 1.6.  Cortisol is normal at 55.0. High sensitive troponin is normal at 10.9.  BNP is elevated at 249. Tsh reflex is low at 0.140. CBC shows leukocytosis at 12.99 and a low hemoglobin at 7.5, a 0.3 decrease from previous results on 3/9/22. T4 Free is normal at 0.8. Procalcitonin Plasma is pending at this time.    The chest x-ray, which was read by the radiologist and reviewed by the ED physician, showed no significant interval change in the extensive airspace disease in both lungs and soft tissue prominence in the right hilar region.    1722: The patient remained tachycardic at 120. The patient was given 25 mg Lopressor for heart rate control.  When I watch the patient's heart rate on the monitor, it is usually 103-110, went into the room her heart rate goes up to 120-130.  She does report significant anxiety.   1752: The patient is resting comfortably in her bed eating spaghetti. No further needs are expressed at this time.    I did talk to the patient and daughter in significant detail regarding her prolonged hospitalization and current symptoms.  I do believe she does have some chronic changes in the lung secondary to her COVID-19 infection.  She is also very decompensated secondary to her long hospital stay.  The daughter is concerned that the rehab facility is not actually doing rehab because of her medical needs and inability to participate.  She just reports significant shortness of breath with any exertional activity.  Review of her chart does reveal that her hemoglobin prior to her hospitalization was low, but usually ran 9.5-10.  She now is 7.5.  I do believe that this is contributing to her symptoms.   1801:  1 unit of packed RBC was ordered for transfusion for treatment of a low hemoglobin.    1913: Spoke with Group, who is agreeable with accepting the patient to the observation unit.    The patient was updated on her results and plan of care, and they verbalized agreement. Orders were placed and the patient was placed in the observation unit in guarded condition. She is a full code.    This patient is still symptomatic with shortness of breath on exertion and frequent syncopal episodes and has not achieved medical stability for safe discharge from the hospital. I am concerned that if discharged today, the current condition will worsen, and an adverse event like respiratory arrest may occur. We will proceed with a medically necessary hospitalization due to the need for blood transfusion, further evaluation, which cannot be achieved safely in an observation or non-hospital setting. Therefore, a full inpatient admission with an expectation of at least two or more midnights (48 to 72 hours) will likely be required to provide the medically necessary services."   Patient met sepsis criteria on admission due to atrial fibrillation with RVR, tachypnea, hypoxia-with acute on chronic respiratory failure.  Cardiology consultant medications adjusted with addition of digoxin and diltiazem.  Blood pressure controlled with continued home medications and antiarrhythmics as noted.  She did have episodic hypotension which responded to fluid bolus and intermittent midodrine.  She continued to have progressive and ongoing dyspnea with bouts of chest pain and anxiety when she was severely dyspneic.  This improved with morphine.  Her generalized pain which was chronic and progressive increase during this admission.  Given goals of care of transitioning to hospice she was continued on fentanyl patch and IV morphine was transitioned to Roxanol.  She had been on morphine previously.  B6 added for chronic pain noting low B6 levels can cause chronic pain.  Additionally she is on chronic Xanax for her anxiety.  This was continued.  She achieved good relief of pain with morphine products.  Xanax and BusPar continued from pre-hospital for treatment of her anxiety noting the anxiety improved with control of her chronic pain and air hunger secondary to her chronic lung disease.   Pulmonary consulted for COVID sequela in setting of chronic lung disease noting history of right lobectomy due to lung cancer.  Steroids started and on discharge she will have a long taper.   She was continued on oxygen at 6 L via nasal cannula noting that initially she had taper down however at time of discharge continues to need 6 L. She was intolerant of CPAP at night.  She is thusly continued on the 6 L via nasal cannula.  Pulmonary has started a Decadron taper.  Inhalers continued. Additional imaging of chest abdomen pelvis were obtained without findings for cancer recurrence.   She was treated for urinary tract infection due to Enterobacter clocae without complications Finding of lichenous skin through the groin area for which hydrocortisone topical cream has been prescribed short term.-continued intermittent treatment pending pain and discomfort.   Shearing over sacral area with barrier creams.    She received Venofer 200mg IV for iron deficiency anemia and to help her oxygen carrying capacity.  B12 continued for macrocytosis and B12 deficiency.  D3 started for vitamin-D deficiency noting deficiency can contribute to anxiety and depression.   Psychiatry consulted for her anxiety and depression.  She had at baseline does have a generalized anxiety disorder which was worsened by her dyspnea and pain.  This is currently controlled.  She also had metabolic delirium which resolved with interventions as outlined above.  There was initial talk about patient going to rehab.  On further discussion with the patient and her family the patient endorsed just being ?tired."  She reported that she is ready to be at the end of her life.  She has goals holding her grand children again.  She does not want to get out of bed to go to the bathroom.  She does not have the energy to participate PT and OT.  She through discussion with myself and palliative Care have opted to pursue hospice care.  Her family has been supportive.  She will discharge to hospice care.  She is DNAR.  Family is supportive.