Age: 64.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Malaise, Myalgia, N-terminal prohormone brain natriuretic peptide normal, Productive cough, Pulmonary oedema
Clinical narrative: Hospitalized (9.21.21 - present);  COVID-19 positive (9.16.21);  fully vaccinated HISTORY OF PRESENT ILLNESS: Patient is a 65 y.o. female with a past medical history of sarcoidosis, OSA not on CPAP, CKD 3B, MGUS, and morbid obesity who presents today with hypoxia.  Her current symptoms started on 9/14.  Symptoms include fevers, chills, rigors, anorexia, dysgeusia, cough, weakness and diarrhea.  She has not taken the majority of her medications in 1 week.  She confirmed that she had not taken her Lasix in 1 week.  The patient received a COVID test on 09/16 which was positive.  She was to have the monoclonal antibody infusion today.  When she went to her appointment, her oxygen level was noted to be in the 60s on room air and was sent to the ER.  The patient arrived on 6 L of oxygen by nasal cannula.  Her oxygen level at arrival was 77% on the 6 L.   she was placed on non-rebreather at 15 L. She was transitioned to high-flow nasal cannula with an FiO2 of 90%.  She was noted to be tachypneic in the ER with a respiratory rate of 30.  She was also tachycardic with pulse of 107.  Labs significant for sodium 133, BUN 25, creatinine 1.66, glucose 234, alk-phos 159, albumin 2.9, AST 137 ALT 100.  CRP was 152.8.  D-dimer 470.  CXR with bilateral perihilar and left basilar opacities. This could represent central pulmonary edema. An atypical infection would be a differential consideration, although the distribution would be atypical for Covid 19 pneumonia.  Patient was given 6 mg of Decadron as well as 40 mg of IV Lasix.  ASSESSMENT / PLAN: Pneumonia due to COVID-19 virus Acute Respiratory failure with Hypoxia Lung Sarcoidosis Acute Systolic Congestive Heart Failure -CXR with bilateral perihilar and left basilar opacities. This could represent central pulmonary edema. An atypical infection would be a differential consideration, although the distribution would be atypical for Covid 19 pneumonia. Symptom onset: 9/14 - positive COVID-19 test 9/16 Symptoms: Chills, fevers, rigors, myalgias, head aches, anorexia, loss of taste and smell, productive cough, dizziness, chest pain, diarrhea, chest pain. Treatment: Remdesivir (starting 9/21 - will need to monitor kidney function and liver function daily), Decadron (started 9/21), Pulmonology consult (hx of Sarcoidosis),  VTE prophylaxis with weight based Heparin, Prone PRN, IS, continuous pulse oximetry, supportive care with PRN Imodium, PRN anti-tussives, PRN anti-emetics, PRN albuterol inhaler.  Given abnormal appearance of chest X-ray will continue IV Lasix 40 mg daily (adjust as necessary)  -Not on current treatment for Sarcoidosis - has not taken her Lasix in one week 2/2 to poor oral intake/diarrhea -Daily weights with I/O, monitor urine output -Given reported chest pain - will obtain EKG now and place on telemetry -Pulm note 8/2021 regarding Sarcoidosis: Multiorgan involvement of sarcoidosis: liver, renal, lung. PET ct in July 2020 w/o evidence of sarcoidosis in heart. MTX stopped July 2020 and her PFTs have been stable since this. NOte from 9.23.21:  Pneumonia due to COVID-19 virus Acute Respiratory failure with Hypoxia H/o pulmonary Sarcoidosis - CXR showed bilateral perihilar and left basilar opacities. - Symptom onset: 9/14, positive COVID test 9/16 - Remdesivir started 9/21 - plan to complete 5 day course - Decadron started 9/21 - plan to complete 10 days - Pulmonology consulted (hx of Sarcoidosis)  - VTE prophylaxis with weight based Heparin - Encourage prone positioning and IS - Supportive care with anti tussives and anti emetics - Lasix decreased to 40mg IV daily   Acute on chronic Systolic Congestive Heart Failure - ECHO from 2019 with LVEF 45-50%, normal diastolic function - LHC from 2020 without any significant arterial disease. EF not noted. - Takes Lasix 40mg PO daily at home - has not taken in one week - Pro BNP normal though may be falsely low due to BMI. CXR suggestive of pulmonary edema. - Continue on Lasix IV as above - Monitor daily weights, I&Os   Pulmonary sarcoidosis - Per pulm note 8/2021 regarding Sarcoidosis: Multiorgan involvement of sarcoidosis: liver, renal, lung. PET ct in July 2020 w/o evidence of sarcoidosis in heart. MTX stopped July 2020 and her PFTs have been stable since this. - Not on active treatment - Pulm following - no need for an acute treatment. - Albuterol INH PRN   CKD IIIB - Follows with Nephrology as outpatient - Creatinine is near baseline at 1.6 - GFR 38 - Monitor closely while diuresing and on Remdesivir - Lasix dosing as above - Daily weights, I/O