Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Confusional state, Coronary artery bypass, Cough, Dizziness, Dyspnoea
Clinical narrative: ED to Hosp-Admission Current 9/10/2021 - present (5 days) Hospital  Acute hypoxemic respiratory failure due to COVID-19    Pneumonia due to COVID-19 virus  1.  Acute hypoxemic respiratory failure and sepsis secondary to COVID-19 pneumonia: -Requested ABG stat.  Pulse ox dropped to 81% on room air due to COVID-19 pneumonia.  Initiated supplemental oxygen, which will be escalated to keep SPO2 above 94%.  To this end, will use high flow O2, NRB, or NIV.  He is a full code. -Sepsis protocol has been initiated.  No indication to continue antibiotics.  Based on hypoxia, keep the patient on systemic steroids (Solu-Medrol 40 mg 3 times daily due to #2), and remdesivir.  The patient also qualifies for tocilizumab or Baricitinib. -Proceed with DuoNeb 3 times daily, and albuterol nebulization as needed due to #2.  Rest of the treatment will be supportive. -Given elevated D-dimer, will follow up with CT chest to rule out PE. -Given lightheadedness and fall, and patient being on Plavix, will get CT head.  Hold Plavix until then.   2.  Exacerbation of COPD: -Secondary to #1.  Continue with systemic Solu-Medrol, duo nebs 3 times daily, and albuterol on as-needed basis.   3.  History of CAD: -Patient has history of coronary stents deployment in the past, and most recently CABG x2 on 6/1/2021 at LGH. -He is currently on Plavix,, Toprol-XL 12.5 mg, and atorvastatin 80 mg daily.  Hold Plavix until CT head results negative for intracranial injury or bleed.  Continue rest of the agents. -His troponin is below the cutoff x1.  Continue to trend.   4.  CKD 3: -Baseline creatinine ranges anywhere from 1.3-1.6, and is currently 1.3. -Continue to monitor.   5.  DM 2: -Patient is on dietary modification alone for treatment of DM 2, and will be covered with sliding scale while patient is on steroids.   6.  Essential hypertension: -Continue Toprol-XL 12.5 mg daily, with hold parameters.   7.  Acquired hypothyroidism: -Continue Synthroid-100 mcg daily as prior.   8.  GERD: -On PPI once daily, which will be continued.   9.  Depression: -The patient takes bupropion 300 mg a.m., BuSpar on 30 mg twice daily, and will is a do not 40 mg daily.  Continue all agents as prior.   10.  OSA: -CPAP to continue through the night.   11.  BPH: -Continue tamsulosin 0.4 mg daily.  Intermittent catheterization for fluid retention.   CODE STATUS: Full DVT prophylaxis: Will initiate subcu heparin once CT head results negative for intracranial bleed or injuries.   History of Present Illness   Patient is an 72 y.o. male, with past medical history of CAD s/p CABG on 6/1/2021, essential hypertension, DM 2, CKD 3, COPD, GERD, dyslipidemia, acquired hypothyroidism, depression and OSA requiring CPAP at night, presented to the ER today, for evaluation of respiratory symptoms.  Of note, his spouse is currently admitted at our facility due to COVID-19 infection, since 9/8.  The patient himself is fully immunized against COVID-19.   Although the patient has been experiencing generalized aches, and myalgias with weakness for the last few days, he started to experience shortness of breath with nonproductive cough within last 2 days.  Today he was noted to be confused by his son, who himself is suffering from Covid infection.  The patient also had a fall in the bathroom today, after he felt lightheaded and generally weak while standing there.  It is unclear whether or not he hit his head.  However the family did not notice any overt bleeding.  Although his family wanted him to come to the ER, the patient was resistant, but finally agreed to be evaluated for his symptoms.    Overall, the patient did not have any symptoms of vomiting, abdominal pain, or urinary symptoms.  There was no overt fever noted either.   In the ER, the patient was noted to have pulse ox of 81% on room air, but improved to 90% on 2 L of O2.   He also triggered SIRS/sepsis based on mild leukocytosis of 12.9, tachypnea of 26 and heart rate of 101.   The patient tested positive for COVID-19 infection.   The blood work was remarkable for D-dimer of 1.6, for which CT PE study is pending.   The patient was given 500 mL of fluid bolus in the ER along with 10 mg of dexamethasone, 1 g of Rocephin, and started on remdesivir.