Age: 86.0
Sex: M
Vaccine: COVID19-2
Symptoms: Metabolic acidosis, PCO2 decreased, PO2 decreased, Pulmonary embolism, Pulmonary hypertension
Clinical narrative: Patient is a 87 y.o. male patient of MD with history of HTN, arthritis, and vertigo presented to Hospital with shortness of breath. Patient found to have COVID-pneumonia, acute PE, AKI, elevated troponins and mild acute systolic heart failure. During his hospitalization, he received Decadron, Remdesivir, and one dose of Tocilizumab for treatment of COVID-pneumonia. He was also started on heparin drip and transitioned to Warfarin with Lovenox bridge. He was originally started on heated highflow oxygen and was eventually weaned down to 3L NC. Labs also revealed elevated troponins as well as mild acute systolic heart failure with ECHO showing LVEF 45% with mildly dilated RV and mild pulmonary hypertension. He was treated with gentle diuresis for a few days. Patient improved throughout his hospital stay. Home O2 eval was completed and patient was sent home with home O2. He was also sent home with HHC to aid in managing Warfarin dosing with plans to follow up with his PCP, Dr. for further medical management. His INR was not therapeutic on discharge, therefore, Lovenox and Warfarin were sent to patient's preferred pharmacy. Patient was due for evening dose of Lovenox but patient's pharmacy did not have in stock until afternoon of 9/16. Discussed with patient who was adamant about getting Lovenox at Pharmacy. Patient understood the risks of going without scheduled Lovenox therapy and was willing to miss the 1-2 doses. His kidney function did improve over the course of his hospitalization. His Lisinopril will be held on discharge with plans to follow up renal function in 1-2 weeks. He was discharged in stable condition with 5 days of Prednisone, 5 days of Lovenox, Warfarin, and Atorvastatin.   Acute Hypoxic Respiratory Failure Severe Sepsis, improving COVID Pneumonia Leukocytosis Presented with 3 days of shortness of breath WBC 15.21, COVID swab positive, VBG pH 7.37, pCO2 36.2, pO2 37, HCO3 20.7, carboxyhemoglobin 1.6, lactic acid 6.0 CXR shows prominent bilateral perihilar bronchovascular markings suggestive of atypical PNA vs. Reactive airway disease CT Pulmonary Arteries shows segmental branch embolus in left upper lobe without right heart strain or pulmonary infarcts MRSA DNA probe negative, Blood cultures NGTD Oxygen sats reportedly in 60s on arrival of EMS, placed on non-rebreather, oxygen sats now 99% on heated highflow Received Duo-neb treatment in ED, Solumedrol 60 mg Scheduled albuterol, IV Decadron, Remdesivir Pulmonology consult, continue AC and steroids, wean HHF as tolerated, appreciate further recs ID consult, continue 10 day course dexamethasone (start date 9/11), 5 day course Remdesivir (start date 9/11), tocilizumab x1 (9/12), appreciate recs Currently on 3L NC sating 89-94%, increase oxygen needs overnight, wean as tolerated WBC count elevated, given clinical improvement and decreased oxygen needs with no other signs of infection, most likely due to steroid administration Home O2 eval, requiring 3L oxygen with ambulation, Home O2 ordered Acute Pulmonary Embolism CT Pulmonary Arteries shows segmental branch embolus in left upper lobe without right heart strain or pulmonary infarcts Oxygen sats reportedly in 60s on arrival of EMS, placed on non-rebreather, oxygen sats high 90s on heated highflow Hypercoagulable state secondary to COVID infection Discontinue heparin drip, transitioned to Eliquis (9/12), however, due to cost of medication on discharge, will start Warfarin INR 1.3 Currently satin 96% on 3L NC Consult Social Work, HHC to monitor and assist with AC bridging   Anion Gap Metabolic Acidosis VBG pH 7.37, pCO2 36.2, pO2 37, HCO3 20.7 Bicarb 18, Anion gap 28, lactic acid 6.0 on admission Lactic acidosis secondary to pneumonia Most recent lactic acid 1.6, Bicarb 19, anion gap 19 Continue to monitor   Elevated Troponin First troponin 88, repeat 126 EKG shows sinus tachycardia without acute ST changes, repeat EKG shows NSR Denies chest pain On heparin gtt ECHO shows mildly reduced left ventricular systolic function with EF of 45 +/- 5%, atypical septal wall motion, right ventricular chamber enlargement, and borderline pulmonary hypertension Consult Cardiology, will continue more involved workup after recovery from COVID, started on moderate intensity statin    Elevated BNP No history of heart failure, no evidence of fluid overload on exam No prior ECHO study Pro BNP 2,926 Likely secondary to PE and AKI on CKD ECHO shows mildly reduced left ventricular systolic function with EF of 45 +/- 5%, atypical septal wall motion, right ventricular chamber enlargement, and borderline pulmonary hypertension Consult Cardiology, will continue more involved workup after recovery from COVID, started on moderate intensity statin  Discontinue IV Lasix BNP pending AKI on CKDIIIa, improving Baseline creatinine 1.1-1.2 Creatinine on admission 1.74 Mild elevation in creatinine compared to yesterday Discontinue IV lasix Hold home lisinopril Avoid nephrotoxic agents   Hyperkalemia Potassium 5.7 on admission, possibly hemolyzed Potassium currently 5.3 Hold lisinopril Continue to monitor   Presumed COPD, without exacerbation 35 pack year history CT Pulmonary Arteries shows chronic interstitial changes as well as emphysematous changes with hazy ground-glass densities to the lungs without discrete infiltrative changes   Diabetes Hyperglycemia Not currently on any home meds BG level 197 on admission A1c 6.5 SSI, consider metformin   Hypertension On home lisinopril Hold lisinopril in setting of AKI   Pulmonary nodule CT Pulmonary Arteries shows 5 mm noncalcified nodule in the left upper lobe