Age: 50.0
Sex: F
Vaccine: COVID19
Symptoms: Chest pain, Computerised tomogram abdomen normal, Computerised tomogram thorax normal, Diarrhoea, Dyspnoea
Clinical narrative: Patient is a pleasant 52-year-old female presented to the emergency department today for chief complaint of persistent hyperglycemia x1 week and nausea/vomiting with poor p.o. intake.  Patient states that she started having flulike symptoms approximately 8 days ago, but was formally diagnosed with COVID on 10/8/2023.  She reports that she was experiencing some increasing shortness of breath with wheezing, was started on a course of prednisone and azithromycin in the ED on 10/8/2023.  She notes that since she has been on prednisone her blood sugar has been elevated to the point that her glucometer just reads "high".  Of note her blood glucose level was 496 upon arrival to the ED during that visit.  She was also started on Humalog 10 units to be given prior to each meal, but notes that her blood glucose remains elevated although she has been compliant with her Humalog.  She notes that she has been experiencing some nausea and vomiting anytime she attempts to eat or drink anything over the last few days.  She does have as needed O2 to use at home since having COVID approximately 2 years ago.  She reports using 2 to 3 L as needed, currently on 2 L nasal cannula resting comfortably.  She denies any current tobacco, alcohol or illicit drug use.  She denies any chest pain, palpitations, cough/sputum, fever/chills, abdominal pain, or diarrhea/constipation. Work-up in the ED: As above patient still had elevated blood glucose level above 500, was given total of 20 units of Humalog in the ED it is now down to 202.  Patient does not meet DKA or HHS criteria at this time.  She was given Phenergan and a small dose of Haldol in the ED with improvement in symptoms.  Still unable to tolerate p.o. intake, and will be admitted for observation until she is able to tolerate p.o. intake and glucose remains stable.  Currently on 2 L nasal cannula with O2 saturation between 91 and 96, otherwise hemodynamically stable.   Clinical Summary Patient was admitted to MedSurg unit for further management of COVID-19 with acute hypoxic respiratory failure.  At home she uses 2 L nightly was requiring 2 to 3 L continuously on admission.  She was placed on Decadron and remdesivir.  Procalcitonin was checked and was negative, patient was monitored off antibiotics.  Overall low concern for superimposed bacterial pneumonia given no significant findings on chest imaging.  She did develop some diarrhea, stool PCR for C. difficile was ordered however diarrhea resolved before this was collected.  Patient reported increased sputum production, a sputum culture was obtained and was negative.  Patient's admission was complicated by severe steroid-induced hyperglycemia with BG as high as 578.  She was placed on Lantus and this was uptitrated to 14 units twice daily with improvement in her glycemic control.  She received sliding scale insulin AC/at bedtime.  Her hemoglobin A1c was checked and was found to have increased from 5.5-10.6.  Patient's oxygen requirement slowly improved throughout her admission.  Her home diuretics were held due to signs of hypovolemia.  She received gentle maintenance IV fluids with overall symptomatic improvement.  On 10/15 she has completed 5 days of remdesivir.  Her oxygen requirements have returned to baseline, she is stable on room air.  Her glycemic control is significantly improved, BG the morning of discharge was 150.  We will discharge the patient home on 12 units of Lantus twice daily as well as her already ordered sliding scale coverage AC.  Patient requests a prescription for a Dexcom which was sent to her pharmacy.  Given her clinical improvement and CT chest without obvious signs of COVID-pneumonia we will forego the remainder of the 10-day course of Decadron due to severe steroid includes hyperglycemia, flushing and suspected gastritis.  Patient is advised to follow-up with her primary care provider within the next 7 days to reassess her glycemic control, she does understand that as she discontinue steroids her blood glucose may be lower.  She is advised to keep close track of her blood glucose and decrease her Lantus from twice per day to once per day if she has blood glucose in the low 100s.  Upon discharge patient can resume all of her home medications including her home Bumex.  She is discharged home in stable condition.   Discharge diagnosis COVID 19 - completed 5 days decadron/remdesivir. DC off steroids d/t excellent clinica improvement and severe hyperglycemia Acute on chronic hypoxic respiratory failure - d/t above, O2 requirements at baseline on DC  Steroid induced hyperglycemia IDDM - A1C 10.6, DC on lantus 12 BID w/ SSI, dexcom ordered Epigastric pain - CT negative, lipase minimally elevated. Suspect steroid induced gastritis, improved w/ PPI Intractable nausea and vomiting - resolved  Atypical chest pain -resolved, EKG baseline Chronic HFpEF History of paroxysmal SVT History of myocardial bridge  Essential hypertension  Obesity