Age: 77.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Respiratory failure, SARS-CoV-2 test positive, Treatment failure, Treatment noncompliance, Ulcer
Clinical narrative: Previous VAERS submitted - Hx VAERS 913318 and 899783 COVID+ 12/5/22.  Vaccination status - pfizer x3 No d/c notes available currently H&P:  CHIEF COMPLAINT: Shortness of breath HISTORY OF PRESENT ILLNESS: Patient presented to the ED for 2 days of shortness of breath. She reports that her symptoms started with some nasal congestion, also cough in which she feels like she was doing well when she could produce sputum but now she cannot cough anything up.  She denies any fever or ill contacts. She endorses swelling of her lower legs, this is new in the past few days. She was admitted to the hospitalist service for aeCOPD 2/2 COVID and with CHF on Oct 4-14th, intubated for 1 day. She was discharged to SAR with a new fitting on her bipap as she was not wearing this at home. She was discharged on Nov 11th.  She reports that she was doing well, had PCP follow-up on 11/18.  Per that note, they report that she was complaining of being tired, but not have any chest pain, significant wheezing, or worsening of her chronic shortness of breath.  They did report that she had a cough and was having hard time coughing up mucus and that she had some trace pretibial edema.  They also state that she has been compliant with her BiPAP.  Her grandson is present bedside, states that that is not quite the case, while she does wear her BiPAP some nights she is not always wearing it.  Also she is wearing her oxygen nasal cannula with her BiPAP mask over it because she does not like when oxygen bleeds in.  He does note over the past 2 days also that she has had some more shaking of her upper extremities than her baseline.  He reports that she has home health care nursing that has been setting up her pill boxes every week.  The patient cannot tell me her medications, she states that her new her inhalers are more affective than her old ones but cannot tell me the names.  She cannot tell me what dose of prednisone she had been on, she says that they arrived via pharmacy and she started taking them.  ED Course- patient was afebrile, borderline tachycardic with a rate of 104, tachypneic with a respiratory rate up to 33. Blood pressure stable.  Oxygen saturation down to 89% on her home O2.  She had increased work of breathing,  initial blood gas with a pH of 7.17 a pCO2 greater than 110. CXR with findings of pulmonary edema and small bilateral pleural effusions.  She was placed on BiPAP.  Remainder of laboratory studies came back with mostly chronic finding aside from her white count which was 17.89.  Rapid viral panel was negative for RSV, influenza and COVID-19.  She will be admitted to the intensive care unit for acute on chronic hypoxic respiratory failure with hypercapnia and exacerbation of diastolic CHF ASSESSMENT/PLAN: Acute on chronic hypercarbic (primarily) and hypoxic (less so) respiratory failure - pH 7.17, CO2 >110 on initial gas - placed on bipap 14/5 40% FiO2 - repeat gas was 7.25, CO2 100.6 and Bicarb 43.4 - treat aeCHF as below  Acute Exacerbation of CHF/HFpEF   - Echo 3/17/2022:  EF 60%, indeterminate for diastolic dysfunction.   - CXR read as pulmonary edema with small bilateral pleural effusions - BNP 987 - 80mg IV Lasix daily  - wears 3L supplemental O2 baseline  - I's and O's  - daily weights  - Physical and Occupational Therapy Evaluations  - morning laboratory studies  Severe O2-dep COPD in exacerbation  - Home oxygen is 3 L. PFT 5/22/2017 showed severe obstructive lung disease with no improvement with bronchodilators - she will be treated with steroids, nebulizers.   - Home:  Spiriva, DuoNeb. Leukocytosis - was on prednisone outpatient, unclear why however pt reports it came via pharmacy   - add procal  - suspect this is steroid induced  - recheck with a.m. complete blood count Hx of COVID.  Remdesivir 10/4-10/8. OSA.  Wears home BiPAP.  Anemia.  Stable from last admission, 9.6  HTN.  Cont home ACE- inhibitor  HLD.  Lipitor 40 mg q.h.s.  Depression.  Zoloft 50 mg daily  Breast cancer.  On Arimidex at home Osteoporosis.  Prolia q.6 months. Chronic neck pain.  Has had cervical fusion. History of splenectomy Noted  Obesity  BMI 37. Patient would benefit from weight reduction   VTE prophylaxis: Lovenox   12/7/22 progress notes - General Medicine: Chief complaint Acute on chronic respiratory failure with hypoxia and hypercapnia Assessment/Hospital Course Patient is a 78 y.o. female w/ a pertinent PMHx of COPD (3L via NC), OSA (noncompliant with home BiPAP), CHFpEF,  who is admitted to Hospital on 11/30/2022 for Respiratory Acidosis due to combined COPD exacerbation and CHF exacerbation.   Acute Exacerbation of COPD Respiratory Acidosis (resolved) Acute on Chronic Hypoxic Respiratory Failure -- Currently on Prednisone 40mg daily -- Symbicort -- DuoNebs This patient will require a non-invasive ventilator due to chronic respiratory failure and COPD.  CPAP and BiPAP trialed and are not effective for her.  Failure to get a non-invasive ventilator will result in increased risk of recurrent hospitalizations, worsening respiratory failure, and ultimately death.   OSA -- BiPAP at night, again, the patient will need a non-invasive ventilator moving forward COVID-19 positive -- pt. Screened prior to placement, which returned positive -- not currently symptomatic, so will not start acute treatment -- monitor Acute on Chronic CHF -- Echo with EF 60% March 2022 CXR on admission with pulmonary edema with small pleural effusions Now appears euvolemic Wears 3L oxygen at baseline I and Os Daily standing weights if possible PT/OT - SAR Daily BMP Depression Assessment & Plan Cont Zoloft H/O splenectomy Assessment & Plan Noted Malignant neoplasm of upper-outer quadrant of right female breast  Assessment & Plan On Arimidex at home Essential hypertension, benign Assessment & Plan Cont Lisinopril 10mg daily Code Status: Full  Dispo: PT was prepared for discharge until COVID screening swab returned as positive.