Age: 77.0
Sex: M
Vaccine: COVID19
Symptoms: Immature granulocyte count, Increased tendency to bruise, Intensive care, Intentional medical device removal by patient, Interventional procedure
Clinical narrative: Hospitalized (1.7.22 - 1.13.22 / RE-ADMITTED 1.17.22 for GI Bleed duodenal ulcer, acute blood loss anemia); COVID-19 positive (1.1.22 - home test/ 1.7.22 hospital); Fully vaccinated - moderna x2 d/c summary from 1.13.22: Discharge Summary MD (Physician) ? ? General Medicine  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: DO Admission Date: 1/7/2022 Discharge Date: Jan 13, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? Type 2 diabetes mellitus with hyperglycemia  01/08/2022 Yes ? Acute respiratory failure with hypoxia and hypercapnia  01/08/2022 Unknown ? Acute hypoxemic respiratory failure due to COVID-19  01/03/2022 Unknown ? Pseudoarthrosis of lumbar spine 05/18/2018 Yes ? Cardiomyopathy  08/16/2017 Yes ? Atrial fibrillation  08/16/2017 Yes ? Allergic rhinitis   Yes ? Hypercholesterolemia 07/13/2010 Yes ? Hypertension   Yes ? GERD (gastroesophageal reflux disease)   Yes   Resolved Hospital Problems No resolved problems to display.    Pre-Existing Active Problems   Diagnosis Date Noted POA ? Hardware complicating wound infection, subsequent encounter 06/08/2018 Unknown ? Edema, unspecified type 08/30/2017 Unknown ? ED (erectile dysfunction) 09/25/2012 Unknown ? Eczema   Unknown ? DJD (degenerative joint disease) 03/01/2010 Unknown     Discharge Disposition:  home health care svc       DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypoxia [R09.02] Acute hypoxemic respiratory failure due to COVID-19  [U07.1, J96.01] Pneumonia due to COVID-19 virus [U07.1, J12.82] Acute respiratory failure with hypoxia and hypercapnia  [J96.01, J96.02] COVID-19 [U07.1]   HOSPITAL COURSE: per HPI:  Patient is a 78 y.o. male with past medical history significant for atrial fibrillation recently started on Eliquis, history of cardiomyopathy with recovered EF, chronic lower extremity edema, hypertension, hyperlipidemia, non-insulin-dependent type 2 diabetes, hypothyroidism and chronic low back pain with chronic opioid use who presents to the emergency department approximately 1 week after being diagnosed with COVID-19 (01/01/2022) with worsening shortness of breath.  Patient began showing symptomatic with generalized fatigue, body aches, sore throat, dyspnea and productive cough.  He received monoclonal antibody treatment on 01/04 but continued to have increased shortness of breath so presented to ED today.  He has been vaccinated with Moderna x2 in 02/2021 but not the booster vaccine.  He is fully oriented but ill-appearing and very fatigued so I question if some of his recall is accurate. He endorses a mildly productive cough originally streaked with bright red sputum but since has become dark brown/dark red and is improving.  He has maintained a decent appetite and continued to take all of his medications including Lasix.  Has chronic lower extremity edema appears stable to him.  Was originally diagnosed with AFib multiple years ago but not on anticoagulation until 2 weeks ago when his PCP recommended restarting Eliquis.  No noted fevers, chest pain, abdominal pain, nausea, vomiting, diarrhea or difficulty urinating.  Non smoking, minimal ETOH use.   On arrival to the emergency room, patient was hypoxic to 75% on room air and tachypneic to respirations 34 and he ultimately required 6 L nasal cannula to maintain O2 sats greater than 92%.  He was quite hypertensive with blood pressure 180s to 200s mmHg systolic which improved after IV hydralazine.  Labs show potassium 3.2, hyperglycemia, NT proBNP 1400, troponins indeterminate downtrending, procalcitonin 0.06 and no leukocytosis.  COVID-19 PCR positive.  CT angiogram thorax was negative for PE but demonstrated scattered diffuse mixed ground-glass opacities and consolidations consistent with COVID-19 pneumonia along with a small left pleural effusion.  Left lower extremity duplex ultrasound was negative for DVT.  Independent review of EKG shows atrial fibrillation at a rate of 89 ppm in without acute ischemic changes from prior.  He was given IV hydralazine 10 mg, home metoprolol 50 mg, Decadron 10 mg and admitted to hospital medicine for acute hypoxic respiratory failure secondary to COVID-19 pneumonia.   in-house:  patient admitted for severe sepsis 2/2 COVID-19 pneumonia with acute hypoxemic respiratory failure as well as acute CHF. moving patient out of the ED was difficult due to his oxygenation requirements possibly necessitating being sent to the ICU, he was on BiPAP and requiring more than 50% FiO2. he was started on decadron, lasix, but not remdesivir due to concerns for fluid overload; he was also started on lantus due to concern for hyperglycemia from his steroids. echocardiogram was unremarkable, no DVT on RLE venous doppler U/S. patient's pCO2 and pH were elevated as well as stable after several hours on BiPAP, he also remained lethargic. ICU was called and he was moved to the unit a few hours after admission on 1/8. patient was placed on BiPAP there and monitored as ICU was planning on intubating him. however he turned around and was stable for transfer later on 1/8. transfer did not take place right away due to bed availability. on 1/10 patient was AAOx4 and said his SOB and cough had improved, he had no other complaints at the time.  Hypoxia improved and patient was continued on Decadron, remdesivir during hospitalization.  Patient was subsequently evaluated by pulmonary rehab prior to discharge recommended 3 L at rest and with activity.  Patient was discharged to complete 10 days of oral Decadron.  Patient required insulin during the hospitalization.  Evaluated by Endocrinology who did not think that patient to be discharged on insulin which was discontinued.  Patient was evaluated by PT and OT recommended home with home health.  Patient was discharged in medically stable condition.  Discharge instructions were discussed with patient.   CONSULTS / RECOMMENDATION:    Consult Orders (From admission, onward)                IP CONSULT TO DIABETES & ENDOCRINOLOGY      Provider:  Diabetes And Endocrinology          INPATIENT PROCEDURES:   BP 152/100  | Pulse 97  | Temp 36.4 °C (Axillary)  | Resp 21  | Ht 1.803 m  | Wt 83.7 kg  | SpO2 95%  | BMI 25.74 kg/m²  FIO2 (%): (S) 40 %  1/8/22 H&P: Admission History and Physical    CHIEF COMPLAINT dyspnea   Assessment/Plan    ASSESSMENT Principal Problem:   Acute hypoxemic respiratory failure due to COVID-19  Active Problems:   Hypertension   GERD (gastroesophageal reflux disease)   Hypercholesterolemia   Allergic rhinitis   Atrial fibrillation    Cardiomyopathy    Pseudoarthrosis of lumbar spine   Type 2 diabetes mellitus with hyperglycemia      PLAN FULL MEDICATION RECONCILIATION PENDING review of medications w/ wife later this AM by pharmacy tech. Many inconsistencies between pharmacy dispense history and patient reported medications. Patient memory questionable due to fatigue from current illness. Ordered eliquis 5 mg BID for afib (started two weeks ago by patient, possibly a sample, no pharmacy Rx visible), lasix, metoprolol and synthroid. Pending verification of eliquis, cozaar, metformin and PPI.   Addendum 0330: VBG shows significant hypercarbia and respiratory acidosis w/ venous pCO2 93 and pH 7.23. C/w ongoing lethargy. Likely multifactorial from poor respiratory compensation for COVID, suspected pulm edema from significant hypertension (flash edema?) and possible oversedation chronic narcotics. No COPD hx. Lethargic but he seems be alert enough to remove a mask. Will trial BIPAP as able due to underlying COVID. IV lasix 40 mg x 1 with concurrent IV potassium 40 mEq. Goal systolic BP 140-160 mmHg.    Addendum 0630:  CO2 improving on BIPAP w/ O2 sats > 95% on 100% BIPAP. Placed on this level of FIO2 per respiratory because he keeps ripping of BIPAP mask and desaturating -- not due to any desaturations on lower level FIO2. Requested safety attendant and for respiratory to reduce FIO2 to maintain sat > 92%. After which time, he should be appropriate for a GMB bed. Approx 600 mL UOP within 1.5 hours of IV lasix. A1c 8.0 and remains hyperglycemic. Started lantus 20 units daily basal bolus insulin (first dose 9 AM)   Lethargy Acute hypoxic respiratory failure 2/2 COVID 19 pneumonia Small left pleural effusion Bilateral mucous plugging CTA thorax 1/8: negative for PE, scattered diffuse mixed ground-glass opacities and consolidations consistent with COVID-19 pneumonia, small left pleural effusion, diffuse peribronchial thickening, scattered mucus plugging bilaterally -Currently requiring 6 L NC with significant tachypnea and conversational dyspnea -Symptom onset 1/1 (7 days PTA), vaccinated w/ moderna x 2 (2/2021) -Doubt bacterial superinfection w/ low procal (0.06) -Outpatient monoclonal antibody infusion on 1/4/21 -Decadron started 1/7 - present -Agreeable to remdesivir but have not started due to concern of volume overload. Re-evaluate after lasix -Concerned for pulmonary edema w/ significant lower extremity edema and accelerated hypertension -Start lasix IV 40 mg BID when potassium replete (home: lasix 40 mg daily) -Update limited echo w/ significant lower extremity edema -Check VBG due to lethargy -CPT and scheduled mucinex for mucous plugging -Daily weights/strict I& O -Trend CMP, CBC, D dimer and CRP -Proning and incentive spirometry discussed and encouraged -Continuous oximetry and telemetry    Asymmetric chronic lower extremity edema, R > L -Unclear if worse from baseline due to poor patient history -Doppler USV left lower extremity negative for DVT, pending RLE U/S  -Updating limited echo -Checking urine protein:creatine ratio -Continue lasix per above   Acute on chronic CHF exacerbation? History of cardiomyopathy w/ recovered EF, in setting of post-operative spinal surgery -EF 40% 8/2017 in setting of post-op complications following -- > 53% 9/2017 -EKG w/o ischemic changes, trops indeterminate and downtrending, NT pro BNP 1500 (no baseline) -Updating limited echo due to ongoing edema  -Lasix per above, daily weights, strict I/O   Accelerated hypertension  Hyperlipidemia -Very hypertensive on presentation in setting of respiratory distress -Improved after IV hydralazine -Endorses antihypertensive compliance but exact home regimen unclear, pharmacy tech to clarify later this AM -Continue metoprolol, lasix and statin. Hold on Cozaar in setting of acute illness -IV hydralazine 10 mg IV q 4 hours prn for systolic BP >160 mmHg -Hold on IV BB pending echo evaluation of systolic function -Goal systolic BP 140-169 mmHg   Atrial fibrillation -Rates adequately controlled thus far -Recently started eliquis 2 weeks PTA -Continue metoprolol and eliquis   Non-insulin-dependent type 2 diabetes mellitus -Diet controlled. Maybe on metformin? -A1 c 6.9 on 03/2021, will recheck -Moderate dose corrective insulin started in anticipation of steroid induced hyperglycemia   Asymptomatic bilateral nephrolithiasis  -incidental finding on CT a/p   Hypothyroidism -Continue Synthroid -TSH 2.3 on 12/2021   GERD -Continue PPI   Chronic low back pain -continue Norco 5 mg-325 mg every 8 hours hours p.r.n. pending improvement in mentation -MAPS confirmed   DVT ppx:  Eliquis Diet:  Diabetic liberal Code status: Full Code per discussion with patient on admission   Updated wife via phone about clinical status and plan of care at 0630. She is home recovering from COVID and would like an update later today. Son added as potential visitor but she is unsure if phone number is correct.   Above assessment and plan discussed with Dr. whose insight is reflected above.       Subjective    HISTORY OF PRESENT ILLNESS Patient is a 78 y.o. male with past medical history significant for atrial fibrillation recently started on Eliquis, history of cardiomyopathy with recovered EF, chronic lower extremity edema, hypertension, hyperlipidemia, non-insulin-dependent type 2 diabetes, hypothyroidism and chronic low back pain with chronic opioid use who presents to the emergency department approximately 1 week after being diagnosed with COVID-19 (01/01/2022) with worsening shortness of breath.  Patient began showing symptomatic with generalized fatigue, body aches, sore throat, dyspnea and productive cough.  He received monoclonal antibody treatment on 01/04 but continued to have increased shortness of breath so presented to ED today.  He has been vaccinated with Moderna x2 in 02/2021 but not the booster vaccine.  He is fully oriented but ill-appearing and very fatigued so I question if some of his recall is accurate. He endorses a mildly productive cough originally streaked with bright red sputum but since has become dark brown/dark red and is improving.  He has maintained a decent appetite and continued to take all of his medications including Lasix.  Has chronic lower extremity edema appears stable to him.  Was originally diagnosed with AFib multiple years ago but not on anticoagulation until 2 weeks ago when his PCP recommended restarting Eliquis.  No noted fevers, chest pain, abdominal pain, nausea, vomiting, diarrhea or difficulty urinating.  Non smoking, minimal ETOH use.   On arrival to the emergency room, patient was hypoxic to 75% on room air and tachypneic to respirations 34 and he ultimately required 6 L nasal cannula to maintain O2 sats greater than 92%.  He was quite hypertensive with blood pressure 180s to 200s mmHg systolic which improved after IV hydralazine.  Labs show potassium 3.2, hyperglycemia, NT proBNP 1400, troponins indeterminate downtrending, procalcitonin 0.06 and no leukocytosis.  COVID-19 PCR positive.  CT angiogram thorax was negative for PE but demonstrated scattered diffuse mixed ground-glass opacities and consolidations consistent with COVID-19 pneumonia along with a small left pleural effusion.  Left lower extremity duplex ultrasound was negative for DVT.  Independent review of EKG shows atrial fibrillation at a rate of 89 ppm in without acute ischemic changes from prior.  He was given IV hydralazine 10 mg, home metoprolol 50 mg, Decadron 10 mg and admitted to hospital medicine for acute hypoxic respiratory failure secondary to COVID-19 pneumonia.   Patient Active Problem List Diagnosis ? Hypertension ? GERD (gastroesophageal reflux disease) ? DJD (degenerative joint disease) ? Hypercholesterolemia ? Eczema ? Allergic rhinitis ? ED (erectile dysfunction) ? Atrial fibrillation  ? Cardiomyopathy  ? Edema, unspecified type ? Pseudoarthrosis of lumbar spine ? Hardware complicating wound infection, subsequent encounter ? Acute hypoxemic respiratory failure due to COVID-19  ? Type 2 diabetes mellitus with hyperglycemia  REVIEW OF SYSTEMS Review of Systems  Constitutional: Positive for appetite change and fatigue. Negative for chills and fever.  HENT: Positive for sore throat.   Respiratory: Positive for cough and shortness of breath.   Cardiovascular: Positive for leg swelling. Negative for chest pain.  Gastrointestinal: Negative for abdominal pain, diarrhea, nausea and vomiting.  Genitourinary: Negative for difficulty urinating.  Musculoskeletal: Positive for back pain (chronic).  Skin: Negative for rash.  Neurological: Positive for weakness. Negative for headaches.  Hematological: Bruises/bleeds easily.            Objective    OBJECTIVE BP 177/98  | Pulse 91  | Temp 97.7 °F (36.5 °C) (Oral)  | Resp 24  | Ht 1.803 m (5' 11")  | Wt 95.7 kg (210 lb 15.7 oz)  | SpO2 96%  | BMI 29.43 kg/m²  Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: He is ill-appearing.     Comments: Sleepy but rouses to voice, tachypenic and conversationally dyspneic  HENT:     Mouth/Throat:     Mouth: Mucous membranes are dry.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.  Cardiovascular:     Rate and Rhythm: Tachycardia present. Rhythm irregular.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard.    Pulmonary:     Effort: No respiratory distress.     Breath sounds: Wheezing and rales (throughout all lung fields) present.     Comments: Conversationally dyspneic and tachypenic, increased work of breathing with abdominal accessory muscle use but does not appear in respiratory distress Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No tenderness.     Right lower leg: Edema (3+ pitting edema to thigh) present.     Left lower leg: Edema (2+ pitting edema of calf) present.  Skin:    General: Skin is dry.     Comments: Cool extremities but dorsalis pedis pulses strong  Neurological:     Mental Status: He is alert and oriented to person, place, and time.     Comments: Very tired and falls asleep during questions but fully oriented and rouses easily to voice   1/18/22 MICU H&P: MICU ATTENDING ATTESTATION   I personally saw and examined the patient and discussed with the resident.  I assessed/reviewed this patient's hemodynamics, cardiopulmonary status, renal function, fluid balance, medications, labs, imaging, analog sedation, mental status (delirium), mobility, nutrition, glycemic control, line-tube-drain necessity, skin status, prophylaxis, disposition, patient/family concerns and daily goals.  I developed a detailed management plan on the basis of these assessments.   Brief exam: He was obtunded on initial exam when rapid response was called, covered in hematochezia with small amount of epistaxis. After resuscitation he was alert and conversant. Cool, pale.    Brief History and Medical Decision-Making: This is a 78 yo male with recent COVID pneumonia, discharged on 1/13 s/p MAB and steroid treatment. Presented with GIB. Found to have duodenal ulcer on EGD 1/17 s/[p cautery and Epi injection. ICU responded to code blue on floor when he had a syncopal event and was acutely hypotensive after passing large amount of hematochezia.    ---Hemorrhagic shock secondary to Duodenal ulcer s/p Endoscopic intervention Resuscitated with PRBCs, 1 unit on 1/17 and an additional 2 units overnight Discussed with GI, but recommended IR intervention, now s/p embolization of the GDAm and duodenal perforator.  Monitor H&H q6 hr Continue protonix gtt.  NPO  Off vasopressors   Lactic acidosis secondary to shock Restrictive lung disease: chronically elevated serum bicarbonate consistent with hypoventilation, avoid hyperoxygenation. Wean for SpO2 goal of 92-96%   --atrial fibrillation Holding metoprolol and Eliquis   Diabetes Mellitus SSI and lantus   Principal Problem:   Acute blood loss anemia Active Problems:   Atrial fibrillation    Type 2 diabetes mellitus with hyperglycemia    Melena   Hemorrhagic shock    COVID-19 virus detected     This patient is critically ill and is requiring active support and intensive surveillance to prevent life threatening clinical deterioration.  I spent a total of  80 minutes in the evaluation and management of this patient excluding all procedures.   MD  Pulmonary and Critical Care Medicine Medical Group    Expand All Collapse All     Hide copied text  Hover for details   CHIEF COMPLAINT: Acute blood loss anemia     Assessment/Plan     ASSESSMENT / PLAN: Patient is a 78 y.o. male with a past medical history of afib on eliquis, recent hospitalization for covid-19 pna 1/7-1/13 discharge on 3L nasal cannula, currently admitted for GI bleeding. Transferred to ICU for continued bleeding and hemodynamic compromise requiring norepinephrine     Hemorrhagic Shock Acute Blood Loss Anemia Upper GI Bleed 2/2 Duodenal Ulcers EGD on 1/17 remarkable for duodenal ulcers treated with epinephrine and cautery, esophageal exudates suspicious for candida Deteriorated on general medical floors with continued melena, hematemesis, and hypotension Last Hgb 6.8, last lactic acid 8.5 Plan - GI consulted, discussed with on-call physician Dr. who recommend IR embolization - IR consulted for urgent embolization - Continue IV PPi - Ordered 2 units pRBC (will be 3 total since admission), consider adding platelets to next transfusion round, if necessary. Transfuse hgb <7.0 - CBC q6 hours, lactic acid q6 hours - Vasopressors prn for hemodynamic support - Hold Eliquis, last dose 1/16   Covid-19 PNA Fully vaccinated, not boosted. Tested positive 1/7, hospitalized 1/7-1/13 S/p monoclonal abs, dexamethasone and Remdesivir, discharged on 3L Plan - Currently on non-rebreather - Last ABG consistent with respiratory acidosis, repeat prn   Atrial Fibrillation Plan - Holding Eliquis and Metoprolol given bleeding and hypotension   Diabetes Mellitus Last A1c 8.0% 1/7 Plan - Basal bolus insulin with 8 units Lantus at night and moderate dose corrective Humalog - Holding home hypoglycemics    Hypertension Plan - Hold home meds given hypotension   Hypothyroid Plan - Home synthroid       Lines: L art line (1/17), L IJ CVC (1/17) Drains: n/a Airway: non-rebreather Diet: NPO VTE Prophylaxis: Contraindicated with GI bleed Code Status: Full - Unknown GI Prophylaxis: IV PPi     Plan was discussed with attending Dr., please see their attestation for further recommendations   DO Internal Medicine     HISTORY OF PRESENT ILLNESS: Patient is a 78 y.o. male with a history of afib on eliquis, DM, hypothyroid, HTN, recent hospitalization from 1/7-1/13 for covid-19 pneumonia discharged on 3L nasal cannula and dexamethasone. Since that time patient has been progressively more fatigued and weak, also noting episodes of melena. Patient was admitted to the general medical floors on 1/17 and underwent EGD which found duodenal ulcers s/p epinephrine and cautery to stop the bleeding. He required 1 unit pRBC at that time. The evening of 1/17 a "code blue" was called due to change in mental status, hypotension, and hematemesis with concern for lack of pulses. ICU team arrived and found pulses remained strong, no ACLS performed. Patient was transferred to the ICU for requiring norepinephrine to maintain adequate mean arterial pressures. Family was updated via telephone    Patient Active Problem List Diagnosis ? Hypertension ? GERD (gastroesophageal reflux disease) ? DJD (degenerative joint disease) ? Hypercholesterolemia ? Eczema ? Allergic rhinitis ? ED (erectile dysfunction) ? Atrial fibrillation  ? Cardiomyopathy  ? Edema, unspecified type ? Pseudoarthrosis of lumbar spine ? Hardware complicating wound infection, subsequent encounter ? Acute hypoxemic respiratory failure due to COVID-19  ? Type 2 diabetes mellitus with hyperglycemia  ? Acute respiratory failure with hypoxia and hypercapnia  ? Acute blood loss anemia ? Melena OBJECTIVE: BP (!) 149/37  | Pulse 118  | Temp 36.6 °C  | Resp 24  | Ht 1.803 m  | Wt 86 kg  | SpO2 100%  | BMI 26.46 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      Appearance: He is toxic-appearing.  HENT:     Head: Normocephalic and atraumatic.  Cardiovascular:     Rate and Rhythm: Tachycardia present. Rhythm irregular.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. No gallop.   Pulmonary:     Effort: Respiratory distress present.     Breath sounds: No wheezing or rales.     Comments: Accessory muscle use On non-rebreather mask Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    Comments: Lower extremities are cold  Neurological:     Mental Status: He is alert.     Motor: No weakness