Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Cough, Drug withdrawal syndrome, Dyspnoea, Fibrin D dimer increased, Frustration tolerance decreased
Clinical narrative: Patient left AMA on 2/7/2022   HOSPITAL COURSE: Patient  is a 65 y.o. male with past medical history of COPD, chronic diastolic heart failure and bipolar disorder presented to ED for evaluation of cough/shortness of breath, found to have acute hypoxic respiratory failure 2/2 COVID-19 PNA. Acute hypoxic respiratory failure Multifocal pneumonia 2/2 Covid?19 Bacterial pneumonia unlikely Hx COPD/OSA Presented with cough and shortness of breath.Hypoxic to mid 80s at RA.  At admit required 4 L via NC and satting mid 90s. Chest x-ray with multifocal pneumonia. Vaccinated Covid x 2 doses, but overdue for booster on 7/2021. Afebrile with no leukocytosis. D-dimer elevated 0.7. Pro-calcitonin not suggestive of bacterial infection. COVID test returned positive 2/4/2022. Started on dexamethasone on admission. Clinically improving. Unfortunately, on 2/6/22, pt requested to leave AMA. After long discussion regarding risks of leaving AMA and medical recommendations, he was agreeable to stay.  Again on 2/7, patient voiced frustration as he wanted to go outside to smoke. See conversation from progress note earlier today. Had long discussion regarding risks of this - (being on O2 with flame around O2 tank vs going outside without oxygen with acute COVID and hypoxia). He felt very anxious without being able to smoke and without his marijuana. After much discussion he was agreeable to try alternative anxiolytics. Later in the evening he voiced frustration and anger in regards to his marijuana being disposed of. He brought a large bag of marijuana to the hospital and per hospital policy this was properly disposed of by security. He was very upset by this and asked to leave AMA. I re-visted him in attempts to further discuss a plan and help meet his needs. He was not interested in staying at the hospital and did not engage in conversation stating "I"m done. I'm not talking anymore, I'm going home".  He called his relative who arranged a ride. Situation was explained to the relative who expressed understanding and is able to accomodate his return. There is concern about his hypoxia and that he may return is this continues/worsens at home.  With his COPD his O2 goal is >88%. Completed 4 day course of dexamethasone, so prescription for remainder of 10 day course sent to pharmacy on file.    Chronic diastolic heart failure No evidence of volume overload - cont PTA lasix 40mg daily   Bipolar disorder/schizoaffective disorder:  Anxiety From progress note on 2/7 prior to AMA DC: 2/7: having very high levels of anxiety. Wanting to smoke which is really important for him and provides stress relief. Offered NRT and other anxiolytics. NRT does not work well for him and he declined. See full discussion above. Likely having some nicotine and cannabis withdrawal (cravings) leading to worsening anxiety (smokes 1-2 ppd and marijuana regularly). As above safety concern for pt to leave floor to smoke given need for O2 and if not on O2 concern for hypoxia. Per charge RN no staffing available to accompany him for smoking off the floor. After long discussion, he is agreeable to try prn ativan for his anxiety. He is hoping he can discharge home tomorrow. Discussed we would continue to work to have his O2 needs stabilized and would have to reassess tomorrow.  - cont PTA buspar, depakote, hydroxyzine, zyprexa   HTN/HLD - cont PTA lisinopril w/ hold parameters - cont PTA statin   Tobacco use: NRT does not work for pt per his report. Still offerred and available prn   Constipation - resolved Pt reports no BM for 1 week at home. No n/v or abd pain. Some distention on exam.  - abd XR w/ gas no e/o obstruction - schedule senna 2 tabs BID and miralax daily - BM 2/6   DISCHARGE DIAGNOSES:  Principal Problem:   Acute hypoxemic respiratory failure Active Problems:   Pneumonia, suspected bacterial