Age: 51.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Atelectasis, Blood creatinine increased, Blood pH decreased, Brain natriuretic peptide increased
Clinical narrative: Hospitalized (11.26.21):  Acute Respiratory failure due to COVID-19 pneumonia;  COVID positive (11.26.21)  Patient is still admitted to hospital; rapid response event this AM (12.3.21) - patient is now intubated  HISTORY OF PRESENT ILLNESS: Patient is a 51 y.o. male with a past medical history of CHF, dilated cardiomyopathy, type 2 diabetes, hypertension, hyperlipidemia and GERD who presents today with chest tightness.  History and physical were performed in the emergency department where patient will board until a bed becomes available, patient's wife was present at bedside. Patient states that he has been feeling poorly since the dual administration of his 1st COVID vaccination and flu shot on November 20th.  He has been feeling fevers, chills and fatigue.  States that measured home temperatures were never elevated.  However, after the 1st few days post vaccination administration, patient reports worsening cough, shortness of breath and chest tightness that worsens with deep inspiration.  He reports intermittent sputum production which is yellow, denies presence of blood.  Patient does endorse that for the past 2 days he has been working on clearing land in building a new home, for which his shortness of breath and fatigue has been a hindrance to his work.  Patient's wife states that patient requested the route to the hospital when his chest tightness was severe in nature, given his cardiac history.  Patient's wife is fully vaccinated.  Patient states he is unaware of any known exposures.  He does not wear home oxygen.  Patient denies headaches, dizziness, abdominal pain, dysuria, hematuria, numbness or tingling in his extremities. In the emergency department patient was afebrile.  He was tachycardic and hypoxic requiring supplemental oxygen saturation.  Initially patient was started on 4 L via nasal cannula, at the time of our conversation he had been increased to 6 L via nasal cannula.  Pertinent lab findings include an elevated creatinine of 2.22.  BNP was within normal limits at 195. Troponins were within normal limits at 20 and then 21 at recheck.  EKG showed normal sinus rhythm.  Chest x-ray showed abnormal opacity in the left upper lobe extending from the hilum, abnormal patchy opacity in the retrocardiac left lung base.  Probable areas of left-sided pneumonia.  Suspect minimal strandy atelectasis in the right lung base as well.  Rapid COVID PCR was positive.  Due to concerns of acute respiratory failure with hypoxia secondary to COVID pneumonia, as well as acute kidney injury, patient was admitted to hospitalist service. Patient is a full code.  Discussed with patient our intention to admit to the hospital, which will include judicious fluid administration, and COVID treatment including Decadron and remdesivir.  I did discuss with patient and his wife at bedside his code status, and his comfort level with respiratory escalation should it be needed.  Patient is agreeable to are all respiratory intervention including mechanical intubation if needed.  Patient states he already feels better and would like to go home, at the encouragement and urging of his wife, patient agreed to stay to be admitted to undergo fluid administration and COVID treatment.  All questions and concerns answered at this time. Brief history and medical decision making:  51-year-old man with dilated cardiomyopathy type 2 diabetes, dyslipidemia and heart failure preserved ejection fraction, presented with shortness of breath.  Patient just received his 1st COVID vaccination and influenza vaccination 7 days ago.  Patient presented with cough sputum production and shortness of breath.  This is accompanied with worsening dyspnea on exertion.  In the emergency department he was hypoxemic and tachycardic.  Chest x-ray revealed left upper lobe opacification as well as patchy opacification in the left lung base.  Procalcitonin elevated.  COVID-19 positive.  Will start treatment for COVID-19 respiratory failure with superimposed bacterial community-acquired pneumonia.  Will start ceftriaxone/azithromycin. Progress note 12.3.21:  Assessment & Plan 12/3 - intubation/mechanical ventilation Requiring norepinephrine, likely due large of the effects of sedation and positive pressure ventilation Check echocardiogram Acute respiratory failure due to COVID-19 Assessment & Plan Tested positive 11/26/2021 Status post remdesivir, finished course Dexamethasone 6 mg/day 11/27 -  12/3 - intubation/mechanical ventilation Lung protective mechanical ventilation, goal tidal volume 4-6 mL/kg ideal body weight Permissive hypercapnia, tolerate pH approximately 7.25 - 7. 40 range Goal plateau pressure less than 30, driving pressure less than 15 Wean FiO2, as tolerated Deep sedation, paralysis Prone position for P/F ratio < 150 Severe COVID pneumonia, severe acute hypoxemic respiratory failure, prior history of cardiomyopathy (ejection fraction normalized on most recent outpatient echocardiogram last month.) Unfortunately, patient required intubation and mechanical ventilation overnight due to refractory hypoxemia and increased work of breathing. Continue deep sedation with propofol/fentanyl; this monitor in place for guidance Continue paralysis Try prone positioning, after patient has central line in place Lung protective mechanical ventilation underway.  Given pH 7.19, increased respiratory rate from 26-32.  Continue peep 16, wean FiO2 as able (currently 100% with PO2 134) Ultrasound upper/lower extremities and perform CT angiogram, rule out clot.  If present, would begin systemic anticoagulation Given history of viral cardiomyopathy, would consider checking echocardiogram to evaluate function Lasix, goal even to negative fluid balance, as tolerated Holding CHF medications, given norepinephrine requirement Continue dexamethasone 6 mg daily, as per protocol Status post empiric ceftriaxone/azithromycin--no indication to resume antibiotics