Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Rhonchi, SARS-CoV-2 test positive, Shock, Sputum increased, White blood cell count increased
Clinical narrative: Hospitalized (12.21.21 - still admitted currently); COVID-19 positive (12.14.21); fully vaccinated PLUS Booster - pfizer x3 H&P: History and Physical Chief complaint Cough shortness of breath   Problem List Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Acute respiratory failure with hypoxia   Diabetes mellitus   HTN (hypertension)     Assessment and Plan Medical Decision Making Patient seen evaluated in room 306 with nursing staff present.  Patient currently is resting comfortably with nasal cannula O2 at 4 L she has no respiratory distress whatsoever at this time.  Patient states that she has been vaccinated 3 times with a booster.  Patient was hypoxic at home but came to the ER for evaluation.  Patient be started on steroids from the severe albuterol MDI.  Patient is not normally on oxygen.       * Pneumonia due to COVID-19 virus Assessment & Plan Continue COVID-19 protocol steroids and remdesivir albuterol MDI.    Acute respiratory failure with hypoxia Assessment & Plan Continue 4 L supplemental oxygen titrate as needed.  Continue steroids remdesivir   Diabetes mellitus Assessment & Plan Glucose monitoring a.c. and bedtime with moderate sliding scale.   HTN (hypertension) Assessment & Plan Will maintain on cardiac monitoring and oral antihypertensives as previously prescribed. Review of Systems Review of Systems See HPI for pertinent positives and negatives, all other systems reviewed and are negative.     Objective BP 131/56  | Pulse 81  | Temp 37.4 °C (Oral)  | Resp 17  | Ht 1.676 m  | Wt 102.8 kg  | SpO2 92%  | BMI 36.58 kg/m²    Physical Exam Vitals and nursing note reviewed. Exam conducted with a chaperone present.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is obese. She is not ill-appearing, toxic-appearing or diaphoretic.     Comments: Patient was examined in room 306 with nursing staff present.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General: No scleral icterus.    Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. No gallop.   Pulmonary:     Effort: No respiratory distress.     Breath sounds: Rhonchi present. No wheezing or rales.     Comments: Patient has rhonchi bilaterally very mild right greater than left., slightly diminished bibasilar breath sounds. Abdominal:     Comments: Obese but nontender no rebound or guarding is appreciated to palpation.  Musculoskeletal:        General: No swelling. Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal   12/28/21 progress note: CHIEF COMPLAINT: Pneumonia due to COVID-19 virus   Length of Stay: 7 days     Assessment/Plan    ASSESSMENT / PLAN:  72 y.o. female admitted on 12/21/2021 with acute hypoxic respiratory due to severe COVID-19 viral pneumonia. MICU consulted on 12/28/2021 for the same.   Assessment and Plan Acute respiratory failure with hypoxia Assessment & Plan Progressive, severe hypoxia since admission due to severe COVID-19 viral pneumonia CXR and CT imaging with severe/progressive bilateral lung infiltrates, L>R, with no obvious PE having been identified on 12/21 CTA chest FiO2 needs escalated from low flow to high flow nasal oxygen, maximal support - with pt intubated 12/27 evening   Current vent settings: FIO2 (%): 90 % Mechanical Rate: 24 breaths/min Set/Target Tidal Volume: 360 PEEP (cm H2O): 12 cm H2O   Current Pplat and DP are acceptable   Sedation: Fentanyl, propofol NMB: Yes, vecuronium (12/27-present) Proning: Yes (12/27-present)   Continue with current lung protective ventilatory strategy - Goal Pplat <30, DP <15, pH >7.25 with permissive hypercapnia if needed Continue with deep sedation, NMB, and proning 16-20 hrs on/4-8 hrs off Trend ABG and oxygen saturations, and wean FiO2 depending on clinical progress - Goal PaO2 55-80, SpO2 88-95% Current PEEP is at 12 - would trial increasing to 14 to see if this helps lung compliance or not Continue tx's for COVID pneumonitis, as below Continue current empiric abx - infectious studies have been sent and are pending; please ensure tracheal aspirate has been sent for cx now that pt is intubated - If work-up negative, would complete abx x 5 days and then observe off of abx Continue diuresis, as needed, for goal even to negative fluid balance   * Pneumonia due to COVID-19 virus Assessment & Plan Date of positive PCR test 12/14. Concomitant flu testing was negative. Presented on 12/21 with >1 week hx of cough, sputum production, and SOB symptoms Hx full vaccination (two initial doses 3/2021, plus booster 10/2021), but likely chronically immunosuppressed due to hx of CLL Intubated 12/27   Steroids: Dexamethasone 6 mg daily (12/21-12/27) Solumedrol 60 mg BID (12/27-present)   Antimicrobials: Remdesivir (12/22-12/12/26) Ceftriaxone/azithromycin (12/26-present)   CRP 38 -> 22 -> 17 D-dimer 1400 (12/21) -> 700 (12/25) -> 1300 (12/28) No convincing evidence of PE on CTA chest 12/21 Pro-calcitonin 0.08 (12/26)   - Continue weight based steroid regimen with solumedrol 60 mg BID - Diuresis as needed, with goal even to negative fluid balance - No evidence of PE thus far, with stable D-dimer. Would continue Lovenox 40 mg once daily for DVT ppx. Trend D-dimer. If increasing, would obtain U/S x 4 to exclude DVT.   Shock Assessment & Plan Mild shock state post intubation Currently requiring low dose NE infusion, 0.02 mcg/kg/min Suspect this is secondary to sedation needs, but cannot R/O concomitant bacterial sepsis definitively Would wean NE as able, goal MAP >65, and just monitor for now Already getting abx in the event of superimposed bacterial sepsis   CLL (chronic lymphocytic leukemia) Assessment & Plan Hx of CLL that has not yet required treatment - observation previously recommended Acute on chronic lymphadenopathy seen on CT imaging of the chest, reactive component due to acute illness on top of chronic component Suspect that her hx of CLL does lend to some degree of chronic immunocompromise which would explain her severe COVID illness despite hx of complete vaccination   Diabetes mellitus Assessment & Plan BG intermittently elevated between 300-400 in the setting of steroid administration and critical illness Continue basal bolus insulin for now, but if no achieving effective control would start insulin gtt Target BG 100-180 in the setting of critical illness   Class 2 obesity in adult Assessment & Plan Body mass index is 36.22 kg/m².   HTN (hypertension) Assessment & Plan BP has been somewhat borderline low over the past couple days BP medications (lisinopril-HCTZ) have been on hold Would continue to hold in the setting of post intubation shock   Discussion Intubated overnight. Deeply sedated, paralyzed, and proned for refractory hypoxemia. Getting high dose steroids and empiric abx. Would continue these therapies. Wean FiO2 as able. Please send tracheal aspirate for cx. Otherwise, plan as above. Prognosis is guarded.