Age: 73.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Acute respiratory distress syndrome, Acute respiratory failure, Angiogram pulmonary abnormal, Anticoagulant therapy, Blood thyroid stimulating hormone normal
Clinical narrative: Patient with 2 Moderna vaccinations, last dose 03/24/22, who admittedto hospital with complications of COVID.  Provider d/c note below:  "Reason for Admission:  74 year old male with PMH significant for CAD status post CABG and multiple stents, chronic angina, AAA status post repair, Insulin dependent diabetes mellitus and hypothyroidism presented with worsening respiratory failure with hypoxia in setting of COVID 19 + status with CT Angio of Chest showing both COVID 19 pneumonia and bilateral subsegmental pulmonary emboli in the lower lobes.  Of note, patient was originally sent home on 1/17/22 from the ER with supplemental oxygen and a 10 day prescription for Decadron for COVID 19 pneumonia.    Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  #Acute hypoxic respiratory failure secondary to COVID pneumonia with ARDS and acute pulmonary emboli.  Not on oxygen before being started on home oxygen 1/17/22 for COVID.  Previously requiring BiPAP therapy now on high-flow nasal cannula which is being weaned. -supplemental oxygen to keep SpO2 greater than 92%, currently on  6 L, discussed with nursing will attempt to wean further today -treatment of COVID and PE as per below -encourage pronation when able, ambulation and IS use -Mucinex   #COVID pneumonia with viral sepsis.   *Discontinued azithromycin and ivermectin patient was taking PTA.  *Patient 1st tested positive on 01/10 on home antigen test. -symptomatic greater than >10 days ago per patient so out of window for remdesivir *Discontinue Decadron 6 mg daily, received 15 days (1/18-2/2) -Discontinued doxycycline and Rocephin after two days on 01/25 given negative procalcitonin x2 and no consolidation on chest imaging -discontinued severe respiratory precautions on 1/30 in conjunction with infection prevention team.   #Acute provoked subsegmental pulmonary emboli, noted on CT Angio on admission with no evidence of right heart strain on CT imaging, minimal clot burden -transitioned from full dose lovenox to Apixaban on 2/3 AM, unclear insurance coverage, will get 30 day free card, will likely need at least 3 months of anticoagulation, will follow-up with PCP whether will need to transition to Coumadin due to cost after 30 days, recommend follow-up with hematology prior to discontinuation of anti-coagulation   # Hyponatremia, resolved, secondary to poor orally intake.  Legionella negative.     #DM2 with hypoglycemia secondary to poor orally intake, hgb A1c 8.2, reviewed home insulin regimen with wife, she reports recent decrease due to decreased oral intake at home, NPH 58 -> 50 units in the morning, 48 -> 44 nightly, insulin regular 8 units as sliding scale for BS > 200 -increased Lantus to 12 units -increased prandial NovoLog from 12 units to 16 units -insulin sliding scale and carb controlled diet -still with hyperglycemia during day, will defer further dose escalation of Insulin with discontinuation of steroids   #CAD s/p CABG and PCI, no chest pain or evidence of ischemia on arrival, negative delta troponin, last echo in 2020 shows EF 65% -continue BB, ACE, plavix, statin, imdur -low dose Aspirin stopped with initiation of anti-coagulation   # history of AAA s/p repair -continue statin and blood pressure control   #HTN, blood pressure somewhat soft -started holding blood pressure medications on 01/31, previously was on home Lopressor 100 2 times a day, lisinopril 20 2 times a day, Imdur 60, restart BB on 2/3, normotensive off other BP meds so will continue to hold and monitor   #Hypothyroid, TSH WNL at 0.67 on 01/23 -continue home levothyroxine 75 daily   #GERD -continue PPI   #Right 2nd toe ecchymosis versus less likely to be developing necrosis due given good right DP pulses and capillary refill to right foot -continue to monitor   Issues Requiring Follow Up: (Who, what, when, and how communicated?)  Follow-up resolution of acute respiratory failure due to COVID 19 pneumonia and pulmonary emboli with PCP, patient will need assistance with deciding on which anticoagulant to continue after 30 day free card for Eliquis due to limited prescription drug coverage; recommend follow-up with hematology in three months to determine whether anticoagulation can be stopped at that time, follow-up history of hypertension (decreased Imdur and Lisinopril doses as patient was normotensive off these medications during hospitalization)"