Age: 79.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Acute respiratory failure, Alanine aminotransferase normal, Anion gap, Anticoagulant therapy, Aspartate aminotransferase normal
Clinical narrative: ED note by Dr. 7/15/22: "Date:  7/15/2022 Primary care provider:  MD Means of arrival:  ambulance History obtained from: patient History limited by: none   Chief Complaint:  Shortness of Breath   HISTORY OF PRESENT ILLNESS   Patient, is a 79 y.o. male who presents to the Emergency Department complaining of shortness of breath. The patient states that he has had symptoms of diffuse body aches, congestion, coughing, and generalized weakness for the past several days after returning from a trip. The patient states that his symptoms have persisted since onset, and he notes that he recently tested positive for COVID-19 on 7/10/22. The patient states that last night around 22:00 he developed a sudden onset of shortness of breath. The patient states that his breathing has been increasingly labored since this time, and he states that he has been unable to catch his breath prior to arrival to the ED. The patient denies any alleviation of his symptoms prior to arrival to the ED with breathing treatments at home, so he called EMS for transport here to the ED. The patient has a history of sleep apnea, diabetes, hypertension, and atrial fibrillation among other conditions. The patient is on the blood thinner Eliquis among other medications at this time. The patient denies symptoms of nausea, vomiting, diarrhea, syncope, fever, headaches, chest pain, abdominal pain, and any urinary or bowel issues. "  H&P note by Dr. on 7/15/22: "Date of Service:  7/15/2022 Patient, 79 y.o. male Encounter Start Date:  7/15/2022 Inpatient Admission Date: 7/15/2022 PCP: MD   Information Obtained from: patient and history reviewed via medical record Chief Complaint:  Shortness of breath   HPI: Patient is a 79 y.o., male who presents with shortness of breath. The patient states that he has had symptoms of diffuse body aches, congestion, coughing, and generalized weakness for the past several days after returning from a trip. The patient states that his symptoms have persisted since onset, and he notes that he recently tested positive for COVID-19 on 7/10/22.  Relates that his symptoms were not severe at that time and he was not hypoxic.  He was not offered Paxlovid due to his medical history and states that he was not offered monoclonal antibodies at that time.  Patient is quadruple vaxxed for COVID, last booster approximately 1 month ago.  The patient states that last night around 22:00 he developed a sudden onset of shortness of breath. The patient states that his breathing has been increasingly labored since this time, and he states that he has been unable to catch his breath prior to arrival to the ED. The patient denies any alleviation of his symptoms prior to arrival to the ED with breathing treatments at home, so he called EMS for transport here to the ED. The patient has a history of sleep apnea, diabetes, hypertension, CHF, permanent pacer and atrial fibrillation among other conditions. The patient denies symptoms of nausea, vomiting, diarrhea, syncope, fever, headaches, chest pain, abdominal pain, and any urinary or bowel issues.   on arrival to the ED the patient was in some moderate respiratory distress, with cough productive of yellowish tan sputum and was immediately requiring supplemental oxygen at 6-8 liters/minute.  Of note patient does wear nocturnal BiPAP for sleep apnea.  Chest x-ray reveals bibasilar patchy infiltrates.  Laboratory evaluation revealed a white count of 10.6 with bandemia and left shift, D-dimer is elevated at 4,958, CRP of 344.7 and LDH of 251. Chemistries otherwise reveal hyperglycemia consistent with his diagnosis of diabetes and stable baseline renal function with creatinine at 2.56.  Confirmatory swab is positive for COVID-19.  He will be admitted with acute hypoxemic respiratory failure likely due to COVID-19 with concern for superimposed bacterial pneumonia.  Assessment/Plan:  Active Hospital Problems   (*Primary Problem)   Diagnosis ? *Acute hypoxemic respiratory failure due to COVID-19  ? Bilateral pneumonia ? OSA treated with BiPAP ? Type 2 diabetes mellitus, with long-term current use of insulin  ? Stage 4 chronic kidney disease  ? Paroxysmal A-fib  ? Chronic systolic congestive heart failure    Acute hypoxemic respiratory failure due to COVID-19 Bilateral pneumonia --elevation multiple inflammatory markers --diagnosed with COVID-19 initially on 07/10 --begin appropriate COVID supplementation --enhanced droplet isolation --begin ceftriaxone and azithromycin for bacterial coverage --inhaled bronchodilators --Pepcid b.i.d. --Solu-Medrol 40 mg b.i.d. --melatonin --serial inflammatory markers --pulse oximetry --telemetry monitoring --close monitoring for decompensation given multiple risk factors for poor outcomes in COVID   OSA with BiPAP --patient states he has been compliant with his nocturnal BiPAP --will continue BiPAP per outpatient orders --may require extension of BiPAP to waking hours as well if respiratory status declines --follows with local pulmonology as outpatient   DM 2 --continue long-acting insulin --SSI protocol --patient advised likely to develop worsening hyperglycemia with steroid therapy --goal glucose 120-180   CKD 4 --continue current medications --continue current diuretic therapy --consult Nephrology   Chronic systolic congestive Heart failure Paroxysmal atrial fibrillation Permanent pacemaker --EKG reflects ventricular pacing --continue anticoagulation with apixaban --continue rate control agents --given bibasilar infiltrates and history of CHF will check BNP --consider echocardiogram"