Age: 88.0
Sex: F
Vaccine: COVID19
Symptoms: Malaise, Oxygen saturation decreased, PCO2 decreased, PO2 decreased, Procalcitonin increased
Clinical narrative: admitted through the emergency room for progressive radiographic  infiltrates, hypoxemic respiratory failure and what appears to be  superimposed COVID pneumonia.  Her history dates back about 2 weeks ago.   There was apparently an outbreak of COVID at the Center and  they have been screening their residents regularly.  She was screened on  Tuesday the 23rd, although at that time she was having absolutely no  cardiovascular or chest complaints.  She went and enjoyed  Thanksgiving with  her family on Thursday and was reported later that day that she was COVID  positive.  She went back to her apartment and has been  sequestered there since that time.  She did well until several days after  Thanksgiving when she started to develop exertional dyspnea and increasing  nonproductive cough.  No fever, no chills, no hemoptysis.  No chest discomfort  of any sort.  Denies palpitations.  She was checking her saturations and they  were dropping into the mid 80s at times and this prompted an ER visit on the  30th.  She wanted to return home after her visit there.  She was saturating  well around 90% prior to discharge.  ABGs at that time revealed a pO2 of 58.5,  pCO2 of 28.  She was given a dose of bamlanivimab and etesevimab (700  mg/1,400 mg) x1 and was discharged back to her apartment.  At rest, she did  pretty well with her O2 sats remaining in the 90+ percent range while, but any activity caused desaturations in the mid 80% range.  I talked  with her son the day before this admission and suggested she go to the  emergency room, but she refused.  On the day of admission, she was still  coughing and short of breath maybe a little worse and she finally agreed to  come in for further evaluation.  She was seen in the ER on the day of  admission and CTA was obtained.  This revealed bilateral interstitial  infiltrates consistent with COVID pneumonia superimposed on her interstitial  changes.  She was given IV azithromycin and Rocephin and I was contacted.  She  was placed on IV heparin and is admitted at this time for further inpatient  treatment.  Her procalcitonin was mildly elevated at 0.12.  CRP was 113.   White count was 7.45 with no shift.  Chemistries looked good.  Renal function  was stable and her troponin was mildly elevated at 0.108.  BNP was normal at  85.  She was admitted with a provisional diagnosis of hypoxemic respiratory  failure secondary to COVID pneumonia with superimposed underlying interstitial  lung disease. She was felt to be sick enough to be in the hospital as we noted.  She was  saturating well on 3 L nasal cannula.  She was begun on Decadron 6 mg daily,  begun empirically on IV antibiotic coverage in light of her elevated sed  inflammatory markers, which may all be secondary to underlying COVID, but we  did cover her with Rocephin and azithromycin.    Her hospital stay was approximately 6 days.  She did get worse for the first  couple of days requiring higher O2 requirements.  She was up to at most 5 L  nasal cannula.  There was never a problem with CO2 retention.  She remained  alert, oriented, and comfortable.  She had a nonproductive cough  intermittently at times and no chest pain or discomfort.  She never had any  febrile course, and all blood cultures remained negative.    We monitored her closely on a daily basis.  She remained on the COVID floor.   She had previously received Regeneron a week before, and the details of this  are outlined in the H and P.    With time, there was slow symptomatic improvement.  She still required oxygen  on the day of discharge, but her O2 requirements were such that we were able  to decrease her rest O2 down to 3 L nasal cannula.  Her pH was 7.44, pCO2 of  31, and pO2 of 62, and she was perfectly comfortable on these settings.  She  will need 4-5 L with activity.    She remained weak and is in need of further home care.  We felt that she may  require skilled care placement, but the family was determined to take her home  with them.  Her daughter took family leave and will be her caretaker, and she  has other children in the area and grandchildren, who can assist in her home  care.  We will arrange for home care as well.  Home O2 was arranged at 3 L at  rest, 4-5 L with exertion as noted.