Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Leukocytosis, Leukopenia, Loss of consciousness, Lung opacity, Malaise
Clinical narrative: Hospitalized (12.7.21 - still admitted currently); COVID-19 positive (12.1.21); Fully vaccinated -pfizer x2 12/15/21 - intubated 12/20/21 - currently still vented and in ICU  12/7/2021: H&P: CHIEF COMPLAINT: Pneumonia due to COVID-19 virus Syncope    Assessment/Plan    ASSESSMENT / PLAN:     Subjective     Covid PNA  Admit to Observation status  Symptom onset 11/28, Covid positive 12/1, day 10 of symptoms  Tachycardic, febrile, tachypnic in ED  Intermittent desat in ED while asleep, I witnessed 89% on RA, daughter at bedside witnessed drop to 87%   Will start remdesivir and decadron 6 mg po daily  CTA thorax shows no evidence of PE, bilateral groundglass opacities consistent with Covid-19 pneumonia present  Continuous pulse ox  Encourage proning Prn tessalon    Mild leukopenia and thrombocytopenia  peripheral smear sent Repeat cbc in am  Check platelets in am before ordering lovenox    Syncope, vasovagal  Sitting on toilet had BM and passed out for a few seconds, came to and family called 911 for weakness  Poor appetite recently in setting of Covid infection  Telemetry  +orthostatics, pt had near syncopal episode while nurse was obtaining vital signs  S/p 1L NS, cont 75 cc/hr IV fluids overnight    Depression  No home meds    Rheumatoid arthritis  On rituxan    VTE ppx Lovenox pending repeat platelet level tomorrow morning    Code status  FULL CODE per patient and daughter      HISTORY OF PRESENT ILLNESS: Patient is a 60 y.o. female with history of depression, obesity, rheumatoid arthritis, recent positive Covid test (vaccinated) presents via EMS after a syncopal episode at home. She was sitting on the toilet and had just had a BM when she passed out for few seconds.  Family noted she was weak afterwards so she was brought to the ER.  Tested positive for COVID on 12/01, her symptoms began on 11/28.  Her family members at home were also sick but have recovered, pt initially got better then began to decline again. Endorses headache, malaise, decreased appetite, shortness of breath, dry cough. Denies N/V/D. Get rituximab injections for her rheumatoid arthritis.   Febrile on arrival to ED, tachycardic, tachypnic. CTA Thorax negative for PE, covid pneumonia present. Near syncopal event in ED while nurse was taking orthostatic vitals. Given tylenol, toradol, 1L NS in ED. Desat to 87-89% in ED so placed on 2L NC. Admit to OBS for Covid pneumonia.  Patient Active Problem List Diagnosis ? Seropositive rheumatoid arthritis (HCC) ? Pneumonia due to COVID-19 virus ? Vasovagal syncope ? Depression ? Hypoxia   Past medical, surgical, family and social history reviewed.    Medical HistoryExpand by Default Past Medical History: Diagnosis Date ? Depression   ? Rheumatoid arthritis (HCC)      Past Surgical History Past Surgical History: Procedure Laterality Date ? HX BREAST REDUCTION     ? HX HYSTERECTOMY (TYPE UNKNOWN)            Social History     Socioeconomic History ? Marital status: Married     Spouse name: Not on file ? Number of children: Not on file ? Years of education: Not on file ? Highest education level: Not on file Occupational History ? Not on file Tobacco Use ? Smoking status: Former Smoker ? Smokeless tobacco: Never Used Substance and Sexual Activity ? Alcohol use: No ? Drug use: No ? Sexual activity: Not on file Other Topics Concern ? Not on file Social History Narrative ? Not on file    Social Determinants of Health    Financial Resource Strain: Not on file Food Insecurity: Not on file Transportation Needs: Not on file Physical Activity: Not on file Stress: Not on file Social Connections: Not on file Housing Stability: Not on file    Family History Family History Problem Relation Age of Onset ? Colon Cancer Father       Prescriptions Prior to Admission (Not in a hospital admission)   Allergies Allergen Reactions ? Hydroxyzine Rash   Review of Systems Constitutional:  Positive for appetite change and fever.  HENT: Negative for trouble swallowing.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough and shortness of breath.   Cardiovascular:  Negative for chest pain.  Gastrointestinal:  Negative for abdominal pain and trouble swallowing.  Genitourinary:  Negative for difficulty urinating.  Musculoskeletal:  Positive for muscle pain.  Neurological:  Positive for headaches, light-headedness and weakness.  Skin:  Negative for rash.          Objective    OBJECTIVE: BP 124/77  | Pulse 79  | Temp 98.6 °F (37 °C) (Oral)  | Resp 21  | Wt 112 kg (246 lb 14.6 oz)  | SpO2 94%  | BMI 42.38 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: She is obese. She is ill-appearing.     Comments: Generalized weakness present   HENT:     Head: Atraumatic.     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: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.     Comments: Deep breath triggers a dry cough  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No tenderness or deformity.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.   12/20/21 progress note: MICU ATTENDING NOTE    I personally saw and examined the patient on ICU rounds.  I assessed/reviewed this patient's hemodynamics, cardiopulmonary status, renal function, fluid balance, medications, labs, imaging, analog sedation, mental status (delirium), mobility, nutrition, glycemic control, line-tube-drain necessity, skin status, prophylaxis, disposition, patient/family concerns and daily goals as part of the ICU checklist.  I developed a detailed management plan on the basis of these assessments.   CHIEF COMPLAINT: SARS pneumonia   Length of Stay: 12 days     Assessment/Plan    ASSESSMENT / PLAN: Acute hypoxemic respiratory failure due to COVID-19 (HCC) Overview Received Pfizer vaccine 4/13/21 and 5/4/21.  Immunocompromised on Rituximab for RA   11/28/21: symptom started 12/1/21: tested positive for COVID-19 12/7/21: admitted for hypoxemic respiratory failure 12/15/21: intubated   Steroids: - Decadron (12/7/21 - 12/15/21) - Solumedrol 40 mg BID (12/16/21 - 12/20/21) - Solumedrol 40 mg daily (12/21/21 - *), plan for slow wean by 10 mg every 3 days based on clinical response.   Antimicrobial regimen Remdesivir (12/7/21 - 12/11/21, 12/14/21 - 12/15/21) Vancomycin (12/15/21 - 12/17/21), empiric for fevers Zosyn (12/15/21 - * ), empiric for fevers   Assessment & Plan Current respiratory support: Device (Oxygen Therapy): ventilator Vent Settings: FIO2 (%): 50 % Type of Mechanical Vent: Hamilton Mechanical Rate: 30 breaths/min Set/Target Tidal Volume: 370 PEEP (cm H2O): 12 cm H2O Lung mechanics: Plateau Pressure: 26 cmH2O Peak Pressure: 30 cmH2O Actual mL/kg: 6.79 mL/kg Patient-ventilator interaction: o synchrony ? Neuromuscular blockade: Yes (12/15/21) o Body Position: per Continuous Lateral Rotation Therapy Sedation: o RASS goal: -5 o propofol o fentanyl VAP prophylaxis: Chlorhexidine    Ventilator Monitoring/Goals Please target: - Tital volume < 6 ml/kg predicted body weight - Plateau pressure < 30 cm H2O - Consider higher PEEP in moderate/severe ARDS - Keep PaO2 55-80 mmHg or SpO2 88%-95% - Allow for permissive hypercapnia, with goal pH > 7.25   Seropositive rheumatoid arthritis (HCC) Overview On Rituximab therapy    Assessment & Plan Immunosuppressed individual. Monitor and treat for other infectious complications.    Diabetes mellitus (HCC) Overview HgA1c 6.8. Not on any therapy as outpatient.    Assessment & Plan Stress and steroid induced hyperglycemia Treat per ICU protocol with insulin drip or corrective.  Goal glucose 100-180   Class 3 severe obesity in adult (HCC) Assessment & Plan Body mass index is 40.27 kg/m².   Overview Per daughters, patient does understand the language, but may not understand medical terms.    Assessment & Plan When weaning sedation, consider in person interpretor to help orient patient.    Depression / Anxiety history Overview Has history of major depression and panic attacks.    Assessment & Plan Monitor for agitation, anxiety as sedation is weaned.    Plan for the day: Shock may be due to sedation, will need to rule out sepsis given rising leukocytosis - antibiotics: zosyn (FD 12/15/21) - repeat blood cultures, tracheal secretion cultures, UA if febrile - obtain KUB r/o ileus, toxic megacolon; c-diff pending (no stool at this time).  Transaminitis likely related to COVID-19 infection, obtain RUQ US r/o cholecystitis Thrombocytopenia mild, will monitor for now  Vent Management - decrease RR today, aim for pH 7.25-7.35 - decrease FIO2 today, aim for O2 saturations 88-94% - keep supine if PF ratio remains stable, if it continues to drop, consider prone position - paralytic holiday planned for tomorrow 12/21/21.  - wean steroids (12/15/21 solumedrol 40 mg q12h, wean to 40 mg daily) - fluid goals: maintain euvolemia - anticoagulation: Lovenox 40 mg SQ q12h   Updated daughter.      This patient is critically ill with the above issues and/or is at high risk for sudden decompensation and death.  45 minutes were spent in the patients evaluation and management excluding time spent on any procedures, and is in addition to any time spent by another provider.         Subjective    SUBJECTIVE: No overnight events       Objective    OBJECTIVE: BP (!) 212/79  | Pulse 63  | Temp 37 °C  | Resp 30  | Ht 1.63 m  | Wt 107 kg  | SpO2 94%  | BMI 40.27 kg/m²  FIO2 (%): 50 % Physical Exam  General:  Intubated, sedated, unresponsive.  Morbidly obese woman. Heart regular rate and rhythm. Lungs clear to auscultations anteriorly Abdomen soft, nontender, nondistended, bowel sounds in all 4 quadrants Extremities warm, no pitting edema in the upper or lower extremities