Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Blood bicarbonate increased, Blood gases abnormal, Blood pH decreased, Blood sodium decreased
Clinical narrative: Discharge Provider: MD Primary Care Provider: MD Admission Date: 11/24/2022 Discharge Date: Nov 26, 2022 COVID positive date: 11/24/2022 PRESENTING PROBLEM: Cachexia (HCC) Respiratory distress  Dehydration, mild  Acute hypoxemic respiratory failure (HCC)  Diarrhea, unspecified type  COVID-19    HOSPITAL COURSE: Patient is a 68 y.o. who presented with shortness of breath.  Patient has advanced chronic obstructive pulmonary disease and is on 2 L of oxygen round the clock at home.  He developed fevers and dyspnea approximately 4 days prior to admission.  Despite adherent use of inhaler therapy his dyspnea persisted.  The patient states that he was exposed to a friend who tested positive for COVID-19.  The patient in fact tested himself multiple x1 of those did result in positivity.  He denies any productive cough, chest pain.  He has had no recent travel and other than his COVID exposure no known sick contacts.  Upon arrival to the emergency department he was noted to be hypoxemic with SpO2 in the 80s.  CXR revealed bilateral diaphragmatic flattening with no infiltrate suggestive of bacterial or viral pneumonia.  Initially a CT angiogram thorax was desired however the patient did refuse this.  Point of care  echocardiogram revealed no evidence of right heart strain, however did show fully collapsible inferior vena cava.   The patient is being admitted to the hospitalist service, for the workup and treatment of chronic obstructive pulmonary disease exacerbation/acute on chronic respiratory failure/possible COVID-19 infection .  COVID-19 sickening bed COVID-19 PCR came back positive, the patient was treated with steroids, supplemental oxygen, and was placed on MedSurg unit for further management.  His symptoms improved, he is back to baseline home oxygen requirement, we will discharge him home and follow up with PCP on outpatient basis.  Readmission from 11/29/2022-12/10/2022 at Hospital notes: Discharge Provider: MD Primary Care Provider at Discharge: MD  Admission Date: 11/29/2022 Discharge Date: 12/10/2022  PRESENTING PROBLEM: Acute respiratory failure with hypercapnia (HCC)  Coronavirus infection  Chronic obstructive pulmonary disease, unspecified COPD type (HCC)  Acute hypercapnic respiratory failure (HCC)  Acute on chronic respiratory failure with hypoxia and hypercapnia (HCC)    HOSPITAL COURSE: HOSPITAL COURSE: Patient is a 68 y.o. male who presents today with shortness of breath.  He has a pertinent medical history for chronic obstructive pulmonary disease on 2 L nasal cannula, cachexia, and positive for COVID-19 on 11/24/2022.  He was recently hospitalized at this hospital from 11/24-11/26 with COVID-19 and chronic obstructive pulmonary disease exacerbation.  He was treated with dexamethasone and sent home on his baseline 2 L nasal cannula.    In the ER he was found to be tachypneic, and tachycardic.  He is able to maintain normal saturations on his baseline 2 L nasal cannula.  Initial lab work shows sodium 129, BNP 174, WBC 4.66, D-dimer 400, and procalcitonin 0.05.  An ABG was obtained which shows pH 7.27, pCO2 75.2, PO2 20.7, and bicarbonate 33.9.  Chest x-ray shows right lung perihilar airspace opacity which may represent atelectasis or developing pneumonia.  Given shortness of breath and hypercapnia patient will be admitted to the hospitalist service.  He was continue on BiPAP. He was continued on dexamethasone and Remdesivir. He was started on doxycycline for anti-inflammatory effect. Supplemental O2 weaned to baseline 2L. PT/OT evaluated recommended SNF. He had persistent tachycardia for which inhalers transitioned to Xopenex. Patient was intermittent administered morphine for air hunger in advanced COPD. On 12/6 he was downgraded from ICU.   Patient continued w/ slow improvement and was able to wean down to his baseline O2 requirements.  While preparing him for discharge, after transitioning him to prednisone, he felt more short of breath and reported that he did not tolerate prednisone in the past.  Prednisone was held and he was observed.   Electrolytes were monitored and repleted PRN throughout the admission. Patient clinically improved and hemodynamically stable for discharge.  Discussed plan of care discharge with patient including outpatient follow-up PCP within 7 days.  Patient voiced understanding was agreeable with plan of care discharge.   A Face to Face Attestation is required for the provision of certified home health services.    Once this attestation form is completed, please copy and paste the attestation below into your visit note.     Face to Face Encounter   I certify that this patient is under my care and that I, or a nurse practitioner or physician's assistant working with me, had a face-to-face encounter that meets the physician face-to-face encounter requirements with this patient on 12/10/2022  (identify the date that the patient was seen for the reason of home care services.  This date can be 90 days prior to or 30 days after the order for home care).   The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care COPD exacerbation.   I certify that, based on my findings, the following services are medically necessary home health services: Nursing:  Cardiopulmonary status and Med use and effectiveness, Physical therapy:  Strengthening/endurance, and Occupational Therapy Home safety and ADL/IADL training.   See History and Physical that support the need for the above services.   Further, I certify that my clinical findings support that this patient is homebound and home is the best place to receive care (i.e. absences from home require considerable and taxing effort and are for medical reasons or religious services or infrequently or of short duration when for other reasons) because: Criteria 1 (one required):  Due to injury/illness, in order to leave the home the patient requires assistance of walker and another person. Criteria 2 (both required):  Exists a normal inability to leave the home due to recent surgery/hospital stay.  Leaving the home requires considerable and taxing effort due to weakness and shortness of breath