Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Alanine aminotransferase normal, Anion gap, Anticoagulant therapy, Anxiety
Clinical narrative: Hospitalized (3.16.22 - 3.22.22); COVID-19 positive (3.16.22); fully vaccinated PLUS Booster pfizer x3 D/c Summary:Discharge Summary MD (Physician) ? ? General Medicine  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 3/16/2022 Discharge Date: Mar 22, 2022 Active Hospital Problems   Diagnosis Date Noted POA ? Hyperlipidemia associated with type 2 diabetes mellitus   06/24/2009 Yes ? COVID-19 03/17/2022 Yes ? Pneumonia due to COVID-19 virus 03/16/2022 Yes ? Chronic diastolic heart failure   03/16/2022 Yes ? Right heart failure due to pulmonary hypertension   08/09/2021 Yes ? Pulmonary hypertension   11/19/2020 Yes ? Bradycardia 08/15/2016 Yes ? Type 2 diabetes mellitus without complication, with long-term current use of insulin   02/24/2016 Yes ? Hypertension associated with diabetes   09/30/2015 Yes ? Restrictive lung disease 10/17/2014 Yes ? Diabetic gastroparesis     Yes ? GERD (gastroesophageal reflux disease)   Yes ? OSA treated with BiPAP   Yes ? Morbid obesity   05/03/2011 Yes ? Severe persistent asthma without complication 10/07/2010 Yes ? Depression   Yes ? CAD (coronary artery disease) 04/11/2009 Yes ? Sarcoidosis 04/11/2009 Yes ? Urge urinary incontinence 04/11/2009 Yes Discharge Disposition:  home health care svc  Active Issues Requiring Follow-up:  Follow up CXR in 2 weeks  Have increased home norvacs to 10 mg daily and hydralazine 25 mg 3 times a day was added. DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Community acquired pneumonia, unspecified laterality [J18.9] Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1] Acute on chronic hypoxemic respiratory failure (3 L NC base)--improving Severe COVID-19 pneumonia Leukocytosis, likely steroid induced Hx mild COVID 11/2021 Mod-severe pulmonary hypertension, 5/2021 Restrictive lung disease 2/2 obesity Severe persistent asthma, not exacerbated Pulmonary sarcoidosis OSA on BIPAP HOSPITAL COURSE: The patient is a 73 yo woman with a PMH of chronic hypoxic respiratory failure requiring 3 L O2 secondary to restrictive lung disease attributed to obesity, pulmonary hypertension, pulmonary sarcoidosis, moderate persistent asthma, chronic diastolic heart failure, coronary artery disease s/p multiple DES, insulin-dependent type 2 diabetes, squamous cell carcinoma and GERD who presents to the emergency department with 8 days of gradual worsening of her chronic dyspnea accompanied by nonproductive cough and fatigue. She was prescribed prednisone 40 mg x 5 days by her pulmonology office which initially improved her dyspnea but then worsened after completing steroids on 3/13.   The patient was admitted for COVID-19 Pneumonia. She is fully vaccinated and boosted and has had prior mild COVID infection in 11/2021. She was placed on Decadron and trial of IV lasix due to findings of mild pulmonary vascular congestion on CXR.  She quickly improved with Decadron and completed 10 day course.  Patient was subsequent transition back to home Lasix 80 mg daily. Patient was discharged in stable condition on 3 L of oxygen at rest and 5 L with activity. Due to uncontrolled hypertension, her home norvacs was increased to 10 mg daily, and hydralazine 25 mg 3 times a day was added.  Patient has been intolerant to higher dose of Coreg so she was kept at 3.25 mg 2 times a day.   CONSULTS / RECOMMENDATION: Consult Orders (From admission, onward)  IP CONSULT TO DIABETES & ENDOCRINOLOGY      Provider:  MD INPATIENT PROCEDURES: BP 159/75  | Pulse 52  | Temp 36.3 °C (Oral)  | Resp 18  | Ht 1.575 m  | Wt 114.8 kg  | SpO2 95%  | BMI 46.29 kg/m²    Physical Exam General:  Alert and oriented.  Obese body habitus Respiratory:  Lungs are coarse to auscultation, Respirations are non-labored.   Cardiovascular:  Normal rate, Regular rhythm. Trace 1+ pitting edema- resolved Gastrointestinal:  Soft, Non-distended Musculoskeletal:  B/L LEs swelling.  Integumentary:  Warm, No pallor.   Psychiatric:  Cooperative but anxious    3/16/22 H&P:  Admission History and Physical   CHIEF COMPLAINT          dyspnea ASSESSMENT Principal Problem :          Pneumonia due to COVID-19 virus Active Problems:   Hyperlipidemia associated with type 2 diabetes mellitus    CAD (coronary artery disease)   Sarcoidosis   Urge urinary incontinence   Depression   Severe persistent asthma without complication   Morbid obesity    GERD (gastroesophageal reflux disease)   Diabetic gastroparesis    OSA treated with BiPAP   Restrictive lung disease   Hypertension associated with diabetes    Diabetes mellitus type 2 without retinopathy     Bradycardia   Pulmonary hypertension     Right heart failure due to pulmonary hypertension     Chronic diastolic heart failure   PLAN Acute on chronic hypoxemic respiratory failure (3 L NC base, 4 L currently)\ COVID-19 pneumonia Leukocytosis, likely steroid induced Hx mild COVID 11/2021 Primary symptoms: cough, worsening dyspnea, malaise, decreased appetite Symptom onset 3/9 (8 days PTA), fully vaccinated and boosted (1/2022) Chest x-ray: moderate alveolar opacification in the left mid and lower lung zone most consistent with left-sided pneumonia and mild pulmonary vascular congestion A&P -Tenuous baseline respiratory status due pulm HTN, pCHF, asthma, obesity -Received outpatient Prednisone 40 mg x 5 days (end 3/13) w/ subsequent symptom relapse -Low concern for bacterial superinfection w/ indeterminate procal but monitor closely w/ leukocytosis (likely steroid induced) and predominately left sided infiltrates -Decadron 6 mg daily started 3/17 -Qualifies for Remdesivir (and amenable) but hold off w/ concern for volume overload -Trial IV lasix 80 mg x 1 on 3/17 for congestion on imaging but appears clinically dry  -Transition back to baseline PO lasix 80 mg pending response -Consider limited echo if not improving (5/2021 w/ nml EF) -Trend daily CMP, d dimer, CRP -Follow blood cultures  Chest pressure, resolved  -Associated w/ movement, improved after decadron? -EKG without acute changes and troponin x 2 normal -D dimer pending with AM labs -Further work-up pending recurrence  Mod-severe pulmonary hypertension, 5/2021 Restrictive lung disease 2/2 obesity Severe persistent asthma, not exacerbated Pulmonary sarcoidosis OSA on BIPAP On 3 L nasal cannula O2 at baseline Follows a pulmonary hypertension clinic with Dr.  -No wheezing on exam to suggest exacerbation. Treating with steroids for COVID regardless -Continue home inhaler regimen:  Symbicort (in lieu of Wixela due to formulary), Spiriva, albuterol p.r.n., Flonase and montelukast -continue nightly BiPAP -Maintain O2 sats 88-92% to prevent hypercarbia  Coronary artery disease s/p DES (2004, 2005, 2006, 2018) Chronic diastolic heart failure 2/2 pulmonary hypertension Hypertension Hyperlipidemia Right heart catheterization/Echo 05/2021:  Preserved EF, moderate right ventricular dilation, mild MR, unable to quantify tricuspid regurgitation -Chest x-ray suggest vascular congestion but clinically euvolemic/hypovolemic with decreasing weight and decreased PO intake -Trial of Lasix 80 mg x 1 on AM of 3/17 (home regimen lasix 80 mg PO daily) -Continue losartan, Imdur, Coreg, ASA and statin -Hold norvasc to allow for diuresis -Daily weights, strict I&O  Hyperglycemia, with reported hypoglycemia Insulin-dependent type 2 diabetes Pseudohyponatremia, secondary to hyperglycemia -A1c 5.9 on 2/22 -Recently decreased home regimen Novolog 70/30 44 units BID -- > 40 units q AM, 35 q PM due to BG in 50s attributed to very poor PO intake (despite steroid burst) -Quite hyperglycemic on admission (due to recent steroids?) -Novolog converted to Lantus 40 units q AM with high-dose corrective -low threshold for involvement  Squamous cell carcinoma Noted  GERD History of esophageal stricture Continue PPI  Overactive bladder Oxybutynin  Depression Celexa  DVT ppx: Lovenox 40 mg BID Diet: diabetic liberal, heart healthy, 2 g Na 2 L fluid restrict Code status: DNR/DNI with aggressive measures per discussion with patient on admission HISTORY OF PRESENT ILLNESS Patient is a 73 y.o. female with past medical history significant for chronic hypoxic respiratory failure requiring 3 L O2 secondary to restrictive lung disease attributed to obesity, pulmonary hypertension, pulmonary sarcoidosis, moderate persistent asthma, chronic diastolic heart failure, coronary artery disease s/p multiple DES, insulin-dependent type 2 diabetes, squamous cell carcinoma and GERD who presents to the emergency department with 8 days of gradual worsening of her chronic dyspnea accompanied by nonproductive cough and fatigue. She was prescribed prednisone 40 mg x 5 days by her pulmonology office which initially improved her dyspnea but then worsened after completing steroids on 3/13. She sought ED evaluation after developing, non pleuritic, nonpalpable central chest pressure on day prior to admission occurring with any exertion and resolving after a few minutes of rest. Has only experienced similar discomfort 6 months ago when treated for COPD flare. Currently pain free after receiving decadron in ED.  a day prior to admission, she desaturated to 86% on her 3 L and temporarily had to bump her oxygen to 4 L, but is now back to baseline O2 needs.  She is typically able to walk several steps before feeling dyspneic but now short of breath with any small movement and at rest.  Has been using albuterol 5-6 times per day (typically once a day) with mild symptomatic improvement.  She feels better when propped up and has increased from 2 pillows to 3 pillows but has no lower extremity edema, decreased urine output or Lasix noncompliance.  Overall she has had poor oral intake past week due to feeling ill and actually lost a documented 28 lb since last month which has been partially intentional.  She lives with her children who are feeling well and denies any recent COVID exposures, sick contacts, fevers, chills, loss of smell, loss of taste, rhinorrhea, sore throat, abdominal pain, nausea, vomiting, diarrhea, dysphagia, choking, dysuria, leg pain or history of VTE.  Fully vaccinated and was treated for COVID-19 with last dose 01/2022.  She previously COVID 11/2021 which is very mild in the not require any specific treatment.  No tobacco or EtOH use.  Compliant with inhalers and nightly BiPAP.    Arrival to the emergency department, she was afebrile, respiration rate 20, mildly hypertensive, heart rate 60s and SpO2 92% on 3 L nasal cannula.  Labs remarkable for sodium of 138, glucose 355, T bili 1.8, NT proBNP 972, troponin 11 with repeat at 10p, leukocytosis of 24,000 but lactic acid of 1.5.  COVID-19 positive but RSV/influenza negative.  Chest x-ray showed moderate alveolar opacification in the left mid and lower lung zone most consistent with left-sided pneumonia and mild pulmonary vascular congestion.  Independent review of EKG shows normal sinus rhythm with left anterior fascicular block, LVH which appears similar to prior EKG. She was given decadron in ED. Admitted to hospital medicine for dyspnea and fluctuating oxygen requirement in the setting of likely COVID-19 pneumonia.  REVIEW OF SYSTEMS Constitutional: Positive for appetite change and fatigue. Negative for chills, fever and unexpected weight change.  HENT: Negative for congestion, rhinorrhea, sore throat and trouble swallowing.   Respiratory: Positive for cough, shortness of breath and wheezing. Negative for chest tightness.   Cardiovascular: Positive for chest pain. Negative for leg swelling.  Gastrointestinal: Negative for abdominal pain, diarrhea, nausea and vomiting.  Genitourinary: Negative for dysuria.  Musculoskeletal: Negative for back pain.  Skin: Negative for rash.  Neurological: Positive for light-headedness. Negative for dizziness and headaches.  Hematological: Does not bruise/bleed easily.  OBJECTIVE BP 170/73  | Pulse 68  | Temp 36.5 °C (Oral)  | Resp 20  | Ht 1.575 m  | Wt 114.4 kg  | SpO2 91%  | BMI 46.13 kg/m²  Physical ExamVitals and nursing note reviewed.  Constitutional:     Appearance: She is not ill-appearing.     Comments: Resting comfortably, mild conversational dyspnea  HENT:    Mouth/Throat:     Mouth: Mucous membranes are dry.     Pharynx: Oropharynx is clear.  Eyes:    Extraocular Movements: Extraocular movements intact.  Cardiovascular:    Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:    Effort: Pulmonary effort is normal.     Breath sounds: Rhonchi (E bilateral rhonchi) present. No wheezing or rales.     Comments: Audible rhonchi, mildly tachypneic with mild conversationally dyspneic Abdominal:    General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:       General: No tenderness.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:   General: Skin is warm and dry.  Neurological:    Mental Status: She is alert and oriented to person, place, and time