Age: 82.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Hypophagia, Hypothermia, Hypoxia, Ischaemia, Lung disorder
Clinical narrative: Hospitalized 10/11/2021; COVID-19 positive 10/11/2021; fully vaccinated  Assessment/Plan    DIAGNOSIS at time of disposition: 1. COVID-19  2. Acute respiratory failure with hypoxia   ED Disposition    ED Disposition   Hospitalized   MEDICAL DECISION MAKING Patient presents to the emergency department with concern for nausea and loss of appetite which is been progressive over the last several weeks, especially worse in the last 3 days.  It at triage patient was noted to be saturating 86% on room air.  She was placed on 2 L nasal cannula and improved to 93%.  Of note patient is not on home oxygen.  Her physical exam is remarkable for a fatigued appearing elderly woman, with crackles across the lung fields bilaterally.  Differential diagnosis includes but is not limited to viral versus bacterial pneumonia, pancreatitis, biliary pathology.  IV access was established she was given 1 L of IV fluids for hydration given reports of poor oral intake, as well as Zofran for nausea. EKG is obtained which does not demonstrate peaked T-waves, evidence of ischemia, or right axis deviation.  No significant changes when compared to EKG from 08/04/2021. Patient has a workup which is significant for positive COVID-19 PCR. Patient is a CT thorax which shows findings consistent with a viral pneumonia, no evidence of underlying bacterial process.  Given patient's hypoxia on room air as well as her tachypnea, she will be admitted to the hospitalist service for continued management.  Patient did not have clinical deterioration while in the emergency department. 10/13/2021 note: ASSESSMENT / PLAN:  Patient is an 83 year old female with CAD status post stenting in 2005, type 2 diabetes mellitus, hypertension, hypertriglyceridemia, and CKD who presented with approximately one month of fatigue and malaise as well as progressive shortness of breath, loss of appetite, and diarrhea. She was found to be COVID-19 positive, despite being fully vaccinated. #COVID-19 pneumonia CT thorax showed peripheral areas of ground glass opacities, consistent with COVID-19 pneumonia. Procalcitonin 0.37, have low suspicion for superimposed bacterial pneumonia, especially given no focal consolidation on imaging. Exact date of symptom onset difficult to ascertain; therefore, is outside the window for remdesivir. National shortage of tocilizumab currently.  Plan:  - Continue dexamethasone 6mg daily x10 days total or until discharge. - Tessalon perles for cough. - Supplemental oxygen therapy as needed 10/15/2021 note: ASSESSMENT / PLAN:  Patient is an 83 year old female with CAD status post stent placement in 2005, type 2 diabetes mellitus, hypertension, hypertriglyceridemia, and CKD who presented with 3-4 weeks of fatigue and malaise as well as progressive shortness of breath, loss of appetite, and diarrhea. She was found to be COVID-19 positive. Her oxygen requirements have been relatively stable; however, she has been intermittently disoriented and agitated, requiring PRN Zyprexa.  #COVID-19 pneumonia Patient's oxygen requirements have been stable to improving. She was on 70% FiO2/50 L/min on high flow nasal cannula at the time of my exam.  Plan: - Continue dexamethasone 6mg daily x10 days total or until discharge. - Supplemental oxygen therapy as needed. - Tessalon perles for cough.  #Hypoxia Most likely secondary to COVID-19 pneumonia, which appeared worse on CTA 10/13 compared to imaging on 10/11. Low suspicion for PE, given no evidence of PE on CTA. Management as above. 10/17/2021 note: Assessment/Plan  Patient is an 83 year old female with CAD status post stent placement in 2005, type 2 diabetes mellitus, hypertension, hypertriglyceridemia, and CKD who presented with 3-4 weeks of fatigue and malaise as well as progressive shortness of breath, loss of appetite, and diarrhea. She was found to be COVID-19 positive, admitted for acute hypoxic respiratory failure likely secondary to COVID pneumonia. # Acute hypoxic respiratory failure #COVID-19 pneumonia # Borderline hypothermia, concern for bacterial pneumonia  Patient has required up to 100% FiO2 over the last 24 hours to maintain her oxygen saturations. CTA performed yesterday, 10/16, for episode of hypoxia out of concern for PE, which was negative for PE but demonstrated worsening pneumonia and left lower lobe airspace disease. Was started on empiric therapy for possible hospital acquired pneumonia yesterday, 10/16. Blood cultures collected 10/16 show NGTD. MRSA nares pending. If negative, can likely discontinue vancomycin. Due to her variable mental state and concern for drying her secretions rendering them more difficult to expectorate, patient would likely not be a good candidate for BiPAP should her respiratory needs continue to escalate. Discussed the option of comfort care with husband, who is patient's DPOA. He was in favor of this but asked me to speak with his daughter, as well.