Age: 94.0
Sex: F
Vaccine: COVID19
Symptoms: Bradycardia, Brain natriuretic peptide increased, Breath sounds abnormal, C-reactive protein increased, COVID-19
Clinical narrative: Hospitalized (12.19.21 - 12.22.21); COVID-19 positive (12.10.21); Fully vaccinated PLUS Booster - moderna d/c summary: Discharge Summary MD (Physician) ? ? General Medicine                      Hospitalist D/C Summary    BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider at Discharge: DO Admission Date: 12/19/2021 Discharge Date:  12/22/2021    Active Hospital Problems   Diagnosis Date Noted POA ? Acute hypoxemic respiratory failure due to COVID-19  12/19/2021 Yes ? CKD (chronic kidney disease) stage 4, GFR 15-29 ml/min  12/19/2021 Yes ? CLL (chronic lymphocytic leukemia)  12/19/2021 Yes ? Pneumonia due to COVID-19 virus 12/19/2021 Yes ? Junctional bradycardia 12/19/2021 Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Acute on chronic diastolic congestive heart failure  12/19/2021 12/22/2021 Yes    Pre-Existing Active Problems   Diagnosis Date Noted POA ? Anemia 11/18/2020 Unknown ? Complete heart block  02/01/2020 Unknown ? Microscopic colitis 03/03/2010 Unknown     DISCHARGE DISPOSITION: The patient was discharged to SNF     No future appointments.   Appointments Needing to be Scheduled  Contact information for follow-up     DO Specialty: Family Medicine Relationship: PCP - General       Next Steps: Follow up   Instructions: Please call to schedule a post-hospitalization follow-up appointment with your Primary Care provider in 7-10 days.  At your appointment, talk to your provider about how you are feeling since being in the hospital.      Instructions for after discharge    Adult Diet   Complete by: As directed     Daily Weights   Complete by: As directed     Early and Progressive Mobility   Complete by: As directed     Occupational Therapy Evaluate and Treat at Receiving Facility   Complete by: As directed     Physical Therapy Evaluate and Treat at Receiving Facility   Complete by: As directed        DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute hypoxemic respiratory failure due to COVID-19  [U07.1, J96.01] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: The patient is a 94-year-old female with a history of CLL on venetoclax, CKD stage 4, chronic diastolic heart failure, stasis dermatitis of her lower extremities as well as junctional bradycardia, who presented with increasing shortness of breath, cough and hypoxia on 12/19.  Patient is fully vaccinated with Moderna vaccination including recent booster.  The patient had the onset COVID symptoms on 12/16 with a positive test on 12/19.  Chest x-ray performed in the emergency department showed prominent interstitial opacities with a component of interstitial pulmonary edema.  COVID testing was negative and the patient was admitted and started on dexamethasone and remdesivir.  ProBNP was elevated on admission at 8461, and the patient received 1 dose of IV Lasix.  Patient's creatinine subsequently increased to 1.81, and further doses of Lasix were held.  Remdesivir was discontinued due to worsening renal function.   With supportive care and further treatment with dexamethasone the patient had improvement in her respiratory status, appetite and oral intake.  She was seen by PT/OT who recommended subacute rehab.  As patient was clinically stable, with stable renal function, stable O2 saturations on 2 L/Min she was transition to oral dexamethasone and discharged to skilled nursing on 12/22/2021.   CONSULTATIONS None   INPATIENT PROCEDURES None   PHYSICAL EXAM: BP 100/73  | Pulse (!) 41  | Temp 36.4 °C (Axillary)  | Resp 20  | Wt 66.7 kg  | SpO2 97%  | BMI 27.06 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed.  HENT:     Head: Normocephalic.     Ears:     Comments: Significant presbycusis present    Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: No oropharyngeal exudate.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Bradycardia present.     Heart sounds: No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.     Comments: Diminished breath sound Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: 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.     Findings: No rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.  H&P: Attestation signed by MD at 12/20/2021  1:55 PM Patient did have some complaints of shortness of breath at the bedside and did have some mild coarse breath sounds heard bilaterally.  Otherwise, patient overall seems to be doing fairly well.  Agree with continued use of diuretics.  Patient asymptomatic in regards to intermittent bradycardia.  Will monitor clinically.  Will need subacute rehab.  Baseline renal function from early 2020 shows creatinine of approximately 1.6 - 1.7 on average.    Expand All Collapse All     Hide copied text  Hover for details   CHIEF COMPLAINT: Acute hypoxemic respiratory failure due to COVID-19      Assessment/Plan     ASSESSMENT / PLAN: * Acute hypoxemic respiratory failure due to COVID-19  Assessment & Plan Likely multifactorial with COVID and CHF On 4L NC Continue lasix and dexamethasone  Wean oxygen as tolerated   Pneumonia due to COVID-19 virus Assessment & Plan Symptom onset: 12/16 Isolation: Severe Respiratory, if improved/afebrile antipyretics consider deescalation on 1/4 due to immune compromised status Vaccination Status: Vaccinated in Feb/March, has had booster although unsure of date Continue supplemental O2, Titrate/wean to maintain SpO2>92% Continue Dexamethasone 1/10 Continue Remdesivir 1/5, will have to continue to monitor renal function closely Encourage Self Prone, IS, deep breathing and ambulation as tolerated  Symptomatic Treatment: Anti Tussives, Anti Emetics, Analgesics VTE PPx: Lovenox 40mg SQ q24 Daily CBC, CMP, CRP, D-Dimer Monitor I/O, daily weight, creatinine Maintain net neutral to negative fluid balance q24 Code Status: DNR     Junctional bradycardia Assessment & Plan Seen by cardiology at Hospital last month, no intervention needed. Daughter states that they spoke with Dr. who said a pacemaker was not needed as her heart never stops and she does not have symptoms with her bradycardia EKG showing junctional rhythm with rate of 46   CLL (chronic lymphocytic leukemia)  Assessment & Plan On venetoclax for CLL, hold with acute infection Follows with palliative care as an outpatient    CKD (chronic kidney disease) stage 4, GFR 15-29 ml/min  Assessment & Plan Renal function appears better than baseline Continue to monitor with diuresis    Acute on chronic diastolic congestive heart failure  Assessment & Plan Patient had an echo in 11/2021 with EF 70% BNP elevated today 8461 CXR showing pulmonary edema vs infiltrates Given IV lasix 20 mg in ER, continue with BID IV lasix Monitor I/O, daily weights               Subjective     HISTORY OF PRESENT ILLNESS: Patient is a 94 y.o. female who presents today with shortness of breath, hypoxia and weakness. The patient has a complex medical history including CKD 4, CLL, bradycardia, CHF, previous DVT not on anticoagulation. She is very hard of hearing and so cannot provide a lot of history due to not understanding all of my questions. I did speak with her daughter on the phone to assist with the history. The patient was hospitalized at Hospital from 11/14-11/19 for a UTI, metabolic encephalopathy and CHF. She was discharged to rehab. Daughter reports that after 9 days she had improved and was told she did not need rehab but was unable to return home so went to another facility for respite. While there she has had increasing shortness of breath but her oxygen levels have been above 90 so she did not need oxygen. The facility reported that over the last 2-3 days she has had increasing weakness. Her daughter states she was there yesterday and she seemed to be at her baseline. Today the patient was found to be hypoxic and so EMS was called and she was brought to the ER for evaluation. The patient states that she occasionally has been having achy chest pain but does not have any today. She has some shortness of breath and an occasional cough. She states she has been tired and had some chills.    In the ER the patient was found to be COVID positive. She had an elevated BNP at 8461. Her troponin was indeterminate with a delta of 3. She had no leukocytosis, a negative procal. Her EKG showed junctional rhythm with a rate of 46 and some ST and T wave abnormalities. She had a CXR showing prominent interstitial opacities bilaterally possible pulmonary fibrosis and or interstitial pulmonary edema and bibasilar atelectasis vs infiltrate. She was hypoxic requiring supplemental oxygen and was given lasix. The hospitalist team was contacted for admission and further management.     Patient Active Problem List Diagnosis ? Microscopic colitis ? Complete heart block  ? Anemia ? Acute hypoxemic respiratory failure due to COVID-19  ? Acute on chronic diastolic congestive heart failure  ? CKD (chronic kidney disease) stage 4, GFR 15-29 ml/min  ? CLL (chronic lymphocytic leukemia)  ? Pneumonia due to COVID-19 virus ? Junctional bradycardia  Review of Systems Constitutional:  Positive for activity change, chills and fatigue. Negative for fever.  HENT: Negative for congestion and sore throat.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for shortness of breath. Negative for cough.   Cardiovascular:  Positive for chest pain (intermittent) and leg swelling.  Gastrointestinal:  Positive for abdominal pain. Negative for nausea, vomiting and diarrhea.  Genitourinary:  Negative for difficulty urinating and dysuria.  Musculoskeletal:  Negative for back pain and falls.  Neurological:  Positive for weakness. Negative for dizziness and light-headedness.  Endo/Heme/Allergy:  Positive for easy bleeding or bruising.  Skin:  Positive for wound. Negative for rash.          Objective    OBJECTIVE: BP 124/55  | Pulse (!) 47  | Temp 36.4 °C (Axillary)  | Resp 28  | Wt 66.7 kg  | SpO2 99%  | BMI 27.06 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is not diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Ears:     Comments: Very hard of hearing    Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Bradycardia present.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.     Comments: Lung sounds diminished in bilateral bases, some scattered fine crackles bilaterally Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: Edema present.     Left lower leg: Edema present.     Comments: LLE>RLE edema  Skin:    General: Skin is warm and dry.     Comments: See photo below of wound on right shin  Neurological:     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.