Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anticoagulant therapy, Antiplatelet therapy, Aortic arteriosclerosis, Basal ganglia infarction
Clinical narrative: Patient is a 84 y.o. female who presented from home on 3/12/2023 with complaints of worsening cough, sob, fatigue. Also noted to have right upper extremity weakness and paresthesias for about two days prior to admit which has now resolved. Underwent lung nodule biopsy with pathology concerning for lung adenocarcinoma. Planning outpatient oncology follow up.         Assessment and Plan   Acute hypoxic respiratory failure Suspect multifactorial in setting of CAP and COPD exacerbation Treated with doxycycline as an outpatient starting 3/6 for acute bronchitis; no improvement of symptoms  CT with left lower lobe consolidation with differential of pneumonia vs underlying mass COVID/Flu negative on admission  -currently stable on RA    COVID 19 - Patient reports worsening shortness of breath  - Symptom onset: diagnosed on march 22nd. Patient with worsening shortness of breath and cough  - Positive COVID-19: March 22nd - Vaccination status: Vaccinated  - Oxygen status: 3 liter/min. At baseline, intermittently on room air maintaining saturation. - Decadron: Yes. Expected end date April 1st - Remdesivir: Yes. Expected end date march 27th   CAP - Treated with doxycycline as an outpatient starting 3/6 for acute bronchitis; no improvement of symptoms  ? Urine antigens negative, sputum culture normal flora  ? Completed rocephin and zithromax course      Acute exacerbation of COPD, suspected  No formal history of COPD but noted extensive smoking history  Reports worsening cough, sputum production, and cough over past 5 days; though could be related to above, suspect aspect of COPD exacerbation given history of reports of clear sputum and wheezing on exam ? Smoking cessation counseled, patient now agreeable to nicotine patch due to possible withdrawal symptoms ? Completed prednisone 40 mg daily x 5 days but currently on dexamethasone for COVID -- Continue current regimen with inhalers SVT, resolved -Intermittent runs of SVT with heart rate in the 130s followed by sinus tachycardia with frequent PVCs seen on telemetry and EKG -Suspect tachycardia due to respiratory symptoms -Started Lopressor 25 mg twice daily -Continue to monitor on telemetry. No further episodes.   Left upper lobe lung nodule CT demonstrates Spiculated nodule left upper lobe 1.5 cm, suspicious for lung cancer and mediastinal lymphadenopathy; Left lower lobe consolidation versus mass 1.5 packs/day x 70 years or so Overall she is fairly robust for her age. No weight loss ? Pulmonary following, CT guided biopsy of LUL nodule completed today 3/16. Pathology showing atypical cells concerning for adenocarcinoma. Need more lesional tissue for more definitive diagnosis. Discussed results with patient, she is wanting to pursue rehab and get stronger before any further workup. She is open to following up with oncology and/or pulmonology outpatient. -- Discussed with pulmonology, patient will need outpatient PET scan and MRI brain with oncology follow up. Oncology navigator on board and coordinating follow-up   Right arm weakness and paresthesias  Etiology concerning for small stroke given improving symptoms of right arm weakness and paresthesias  Current neurologic status: Paresthesias have resolved but still with slight right arm drift and trace right peripheral vision deficit  ? Labs/diagnostics:             CT: No acute findings             MRI/A: Patient would not tolerate at present due to her respiratory status             EKG:    NSR             HgbA1c: 5.3             FLP: 90 ? Antiplatelets/Anticoagulation: Started on 81mg ASA; will await neurology consultation for recommendations  ? Statin: Increased home dose to 20mg atorvastatin ? BP goal: Normotensive given symptom onset >48hours ? DVT prophylaxis: Lovenox ? Other Neurology recommendations:Discussed with neurology, repeat CT head with remote left basal ganglia infarct as well as 2 right frontal lobe hypodensities concerning for age-indeterminate infarcts.  MRI brain recommended with and without contrast however due to claustrophobia and tenuous respiratory status this has been deferred.  Can follow-up with general neurology as needed.  Continue aspirin and statin.   Aortic atherosclerosis Elevated troponin  EKG non acute and patient without chest pain ? Initiation of aspirin as above ? Atorvastatin 10 mg home dose increased to 20mg daily  ? No indication for further cardiac workup at present    Urinary retention Low volume; likely situational - No current urinary complaints  UA essentially unremarkable  ? Continue bladder scans, straight cath as needed  CKD IIIBdi Known history  ? Cr stable, at baseline   Psych disorder not otherwise specified Tapering off of bupropion with plans to transition to escitalopram 10 mg PCP notes reviewed and base on notes, patient should be be on last week of taper (75mg daily) for one more week ? Continue bupropion 100mg daily as 75mg non formulary; pending clinical course, can continue 75mg taper with transition to lexapro as previously discussed with PCP ? Melatonin for sleep   Chronic pain ? Continue tramadol, scheduled Tylenol, lidocaine patches   Tobacco abuse Smoking history as above ? Declines NRT at this time