Age: 81.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Lung infiltration, Mental status changes, Metabolic encephalopathy, Metabolic function test, Metabolic function test abnormal
Clinical narrative: Hospitalized (12.19.21 - still currently admitted); COVID-19 positive (12.19.21); fully vaccinated PLUS booster CHIEF COMPLAINT Lethargy, fatigue, confusion, fever HISTORY OF PRESENT ILLNESS Pt is a 81 y.o. male with past medical history significant for coronary artery disease, essential hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, prior history of DVT, OSA, persistent atrial fibrillation on Eliquis, CKD 4 who presented to the ED on 12/19 for evaluation of confusion, fever, and shortness of breath which started in the middle of the night on 12/18-12/19.  Throughout the day of 12/19 the patient tells me he has not wanted to do anything but sleep, which was concerning to his wife.  He was recently admitted 12/15 through 12/18/2021 at a local Hospital for AKI which was thought to be secondary to a combination of over-diuresis and hypotension. Medications were adjusted; he stopped losartan and started torsemide 20mg daily. He reports compliance with this on the one day he has been home for.  His main complaints are severe fatigue, fever and dyspnea. He is oriented x 4 at the time of my exam, but does fall asleep frequently. He reports increased thirst and poor intake. Denies diarrhea/nausea/vomiting. Denies chest pain or palpitations. Making urine and denies dysuria.  He does tell me he has not been compliant with his CPAP.  He expresses frustration that he is here with COVID.  Tells me he has done everything right, got his vaccines earlier this year, wears a mask.  He is understandably frustrated that he got COVID, as he probably got it in the hospital.  COVID 19 infection - Symptom onset 12/19  - Vaccination status: vaccinated with pfizer 1/26/21, 3/8/21, has not been boosted - Currently requiring 1 L O2 - CXR independently reviewed, with stable cardiomegaly and pulmonary vascular congestion  - Received decadron in the ED, continue for now - Monitor daily covid immunology labs - VTE prophylaxis with home eliquis - IS q 1hr while awake, prone positioning prn Metabolic encephalopathy, improving  Suspect due to combination of fever and hypoxia in the setting of covid 19/volume overload vs. Accumulation of home pain medications in the setting of poor renal function  - CT head independently reviewed, negative for acute intracranial process - Blood cultures x 2 obtained  - Oriented x 4 on my exam, but quite somnolent  - VBG on presentation with pCO2 36, will repeat on a.m. draw - Encourage cpap compliance, patient states he has not been wearing at home - Neuro checks q 4 hours  Mild acute hypoxemic respiratory failure, resolved - Patient was in respiratory distress and hypoxic to the 80s when picked up by EMS, requiring 4L NC  - He has since been weaned to room air  - Unclear cause. COPD vs. covid 19 vs. CHF ?  - Only had 350ml out with lasix, but on my exam looks euvolemic, no wheezing on exam... feel it's reasonable to continue decadron for now   Chronic systolic CHF EF 44% 6/14/21 - CXR independently reviewed, with stable cardiomegaly, mild-moderate persistent CHF, actually improved from 12/17 - BNP 15147 - S/p 40mg IV lasix in ED with only 350ml UOP - Reports compliance with 20mg PO torsemide at home  - Wean oxygen as tolerated - Telemetry, continuous pulse ox - Daily weights, strict I/O, 2g Na/2L fluid restriction Troponin elevation  Type 2 MI in setting of demand ischemia  - Hstnt 171-- >168 - EKG independently reviewed, with atrial fibrillation, rate 74, stable RBBB, unchanged from 5 days ago - Suspect troponin elevation is related to demand ischemia in setting of volume overload/CHF exacerbation  - Denies chest pain  - Telemetry AKI on CKD 4 - Patient was hospitalized 12/15-12/18 and nephrology was consulted at that time - Losartan d/c'd on recent admission - Creatinine 3.01, (recent baseline appears to be 2.5) - Nephro - trend BMP  - hold home torsemide for now