Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Leukocytosis, Livedo reticularis, Lung opacity, Nausea, Neck pain
Clinical narrative: Patient vaccinated 2/24/2021, admitted 7/31/2021, tested positive for covid 7/31/2021. discharged 8/5/2021 to Home with Home health  Event Description: Patient received Pfizer COVID vaccine on 1/30/21 & 2/24/21 (lot #s EL9265 & EN6189, respectively). However, he presented with dyspnea and subsequently tested positive for COVID on 7/31/21  History Of Present Illness Patient is a 77 y.o. male with a PMH of HTN, hypothyroidism, gout, prostate cancer s/p prostatectomy and immune/radiation therapy, colon cancer s/p partial colectomy on 7/27/21 at hospital who presents with a chief complaint of dyspnea. The patient's wife is present with him at bedside and provides most of the history as the patient falls back asleep quickly with questions. She states that around the time of his surgery she noticed he had developed a cough and after the surgery he wasn't "bouncing back" like he should. The following evening he ran a temperature of 102.4 degrees. She states she called the surgeons and they advised her to give him tylenol and come into the office next day if the fever recurred. However, he did not have any further fevers. After this he began to develop more difficulty breathing and hot/cold flashes to the extent that this morning she reports he was diaphoretic and breathing very fast and started coughing again so she called 911. The cough has been nonproductive. He denies any HA, rhinorrhea/congestion, ST or change in smell or taste. They have been around other family members that have Covid-19 and believe they were both infected. He was vaccinated for Covid on 2/10/21 and 2/24/21.    Of note, he has not had a bowel movement still since his surgery. He endorses anorexia and nausea but no vomiting. He has some abdominal pain since the surgery, worse with movement and in the RLQ. His wife states she has had to force him to drink liquids and he has not eaten much. His wife reports that he has not moved around as much due to his pain but she has been hesitant to give pain medications that would worsen his constipation. She also says that he had two colonoscopies prior to his surgery on 7/19 and 7/23. After the second bowel prep she states he became mottled all over his and his knees and elbows went purple. He would shiver but did not have a fever. These symptoms persisted for roughly one day and then resolved.    Review of Systems  Constitutional: Positive for chills, diaphoresis, fatigue and fever.  HENT: Negative for congestion, rhinorrhea, sinus pressure, sinus pain and sore throat.        Some pain in neck/throat with deep breath  Eyes: Negative for visual disturbance.  Respiratory: Positive for cough and shortness of breath.   Cardiovascular: Negative for chest pain, palpitations and leg swelling.  Gastrointestinal: Positive for abdominal pain, constipation and nausea. Negative for abdominal distention, diarrhea and vomiting.  Genitourinary: Negative for difficulty urinating and dysuria.  Musculoskeletal: Negative for joint swelling.  Skin: Negative for rash and wound.  Neurological: Positive for light-headedness. Negative for weakness, numbness and headaches.  Hematological: Does not bruise/bleed easily.  Psychiatric/Behavioral: Negative for confusion.    ASSESSMENT AND PLAN:  Patient is a 77 y.o. male with a PMH of HTN, hypothyroidism, gout, prostate cancer s/p prostatectomy and immune/radiation therapy, colon cancer s/p partial colectomy on 7/27/21 at hospital who presents with a chief complaint of dyspnea. The patient's wife is present with him at bedside and provides most of the history as the patient falls back asleep quickly with questions. Patient never felt fully normal after his surgery and had a cough for about a day, then a day later had a singular fever up to 102.4 degrees which resolved. However he progressively developed worsening chills, diaphoresis, dyspnea and finally a return of cough. His breathing was rapid this morning and he was very diaphoretic so his wife called 911. He has not had a BM since surgery and has had a poor appetite. Has some abdominal pain worst in the RLQ. They have been exposed to family diagnosed with Covid-19.    On admission, the patient was hypoxic with an 02 sat of 88 on RA, now stable on 2L NC to maintain oxygen >92%, RR intermittently >20. He is otherwise afebrile and HD stable. Labs on admission significant for leukocytosis (WBC 16.19), Macrocytic anemia (Hgb 11.3, MCV 99) and elevated inflammatory markers. His CMP is largely unremarkable - GFR is slightly reduced at 57 with normal Cr, hypoalbuminemia, hypocalcemia and mild hyponatremia noted, otherwise normal. CXR and CTPE obtained in the ED concerning for infectious etiology. EKG reviewed, NSR, no ST elevation, QTc <500. Covid test ordered. Patient was given a dose of decadron and medicine was consulted for admission.    Acute hypoxic respiratory failure due to confirmed Covid-19 infection  - patient presents with dyspnea, dry cough, recent fever, chills and diaphoresis, oxygen of 88% on RA on presentation, improved to >92% on 2L NC (No home baseline oxygen requirement or lung disease)  -Meeting sepsis criteria with WBC >12, RR>20 - elevated CRP (487.9), LDH (272), Ferritin (976) on admission - CXR personally viewed with increased LLL opacity noted. Report reviewed and notes left infrahilar opacities concerning for possible atypical pneumonia. CTPE performed showed ground glass opacities consistent with evolving pneumonia such as Covid 19, no PE. - s/p 1 dose of decadron in the ED  - pro-calcitonin elevated at 2.29, consider initiation of abx if clinically worsening or cultures positive for bacterial source of infection  Plan:  - blood cultures, UA and culture, PT/INR, D-dimer, lactate, VBG ordered and pending  - Continue oxygen supplementation to maintain saturation >92% - continue dexamethasone, initiate remdesivir per protocol as patient meets criteria due to new oxygen requirement with o2 saturation of 88% on RA - monitor cbc w/diff, crp, PT/INR and LFTs daily  - consider tocilizumab if oxygen needs continue to increase  - will hold additional antimicrobial therapy at this time    Colorectal cancer s/p partial colectomy with possible developing ileus  - Reports some anorexia and nausea, no BM since surgery. Spoke with his surgeon and he had some post-op ileus but tolerate PO liquid intake with passage of gas - tender RLQ but overall pain is improving since surgery, non-distended   - KUB without signs of obstruction or pneumoperitoneum  Plan:  - allow PO fluids, start IVF at 75ml/hr x 10 hours due to reduced PO intake, monitor for volume overload  - full liquid diet, progress as tolerated  - tylenol for pain, bowel regimen as needed - avoid stimulant laxatives or enema due to low-anastomosis and recent surgery    Macrocytic anemia  - hgb 11.3, down from 12.3 on 7/2 prior to surgery, suspect drop is post-operative, MCV unchanged at 99 - continue home B12 supplementation  - continue to monitor with daily labs, transfuse for hgb <7    Chronic stable conditions HTN- continue home lisinopril (Cr 1.24, GFR 57 on admission, appears near baseline, Cr 1.28/ GFR 54 on 7/2, previously Cr 1.15 on 3/2/21) Hypothyroidism - continue home synthroid  Glaucoma - continue home timolol drops  Gout - continue home allopurinol, no joint swelling or redness at this time, no acute flare   Osteoarthritis - continue duloxetine 30mg BID for pain Seasonal Allergies - continue home zyrtec    Hospitalization Admit Date/Time: 7/31/2021  7:26 AM Discharge Date: 08/05/21 PCP name and Address:  No Pcp None Referring provider name and address:  No referring provider defined for this encounter.   Chief Concern, Brief History of Present Illness, and Hospital Course Patient is a 77 y.o. male with a history of HTN, primary hypothyroidism, gout, prostate cancer S/P surgery + IT/HT, CRC S/P colectomy 7/27 who presented with CoVID-related pneumonia complicated by acute hypoxemic respiratory failure.   1. Acute hypoxic Respiratory failure, due to COVID-19 Pneumonia (POA, Improving) - Onset of symptoms 7/28/2021 - Coronavirus PCR confirmed here in ED.  - Blood cultures are pending, no additional antibiotics currently, however pro-calcitonin elevated at 2.29, consider initiation of abx if clinically worsening with special attention to possible intraabdominal sources given recent surgical intervention.  - Continue oxygen supplementation to maintain saturation >88% - Going home with 2L NC - Continue dexamethasone (last day 8/9/2021) - Finish his 5-day course of remdesivir 8/4 without complications - Filed for Pfizer vaccine failure through the FDA portal - He's advised to follow up with his PCP as scheduled    2. Colorectal cancer s/p partial colectomy with possible developing ileus (POA, Stable) - Reports some anorexia and nausea, no BM since surgery.  - KUB without signs of obstruction or pneumoperitoneum. Continues to pass gas  - Mechanical soft diet - Tylenol for pain and fevers - Continue with Miralax and psyllium  - Avoid stimulant laxatives or enema due to low-anastomosis and recent surgery - Discharged with MOM nightly as needed as well   Chronic Medical Conditions   1. Macrocytic anemia - Continue home B12 supplementation. Will continue to monitor with daily labs, transfuse for hgb <7 g/dL. 2. HTN - Continue home lisinopril, added nifedipine for elevated pressures on 8/1 3. Primary Hypothyroidism - Continue home synthroid  4. Glaucoma - Continue home timolol drops  5. Gout - Continue home allopurinol, no joint swelling or redness at this time, no acute flare   6. Osteoarthritis -Continue duloxetine 30mg BID for pain 7. Seasonal Allergies - Continue home zyrtec 8. Overweight - Complicates all aspects of care