Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Lung opacity, Mean cell volume normal, Metabolic function test, Muscle twitching, Myoclonus
Clinical narrative: Hospitalized (1.24.22 - 1.27.22); COVID-19 positive (1.19.22); fully vaccinated PLUS Booster - pfizer x3 Discharge Summary  Admission Date: 1/24/2022 Discharge Date: 01/27/2022    Active Hospital Problems No active problems to display.   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Acute respiratory failure due to COVID-19 01/24/2022 01/27/2022  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypoxia COVID-19 virus detected Acute respiratory failure due to COVID-19   HOSPITAL COURSE: Patient is a 69-year-old male who presented to the emergency department with chief complaint of worsening shortness of breath, cough with a known diagnosis of COVID-19.  Patient is vaccinated and boosted.  In the emergency department, patient was tachycardic, tachypneic and hypertensive.  He was found to be hypoxemic on room air and placed on supplemental oxygen.  Patient was admitted to the internal medicine service and started on Decadron and remdesivir.  Patient did improve during his hospital stay.  He was able to be weaned from supplemental oxygen.  He was feeling better on the day of discharge.  He was discharged home on Decadron to complete his 10 day course.  He was recommended to follow up his primary care physician.  He was discharged home in stable condition.   CONSULTS / RECOMMENDATION: None   INPATIENT PROCEDURES: Surgery and Procedures    None BP 138/76  | Pulse 56  | Temp 36.4 °C (Oral)  | Resp 20  | Ht 1.905 m  | Wt 104 kg  | SpO2 94%  | BMI 28.66 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress. HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.  Eyes:     Extraocular Movements: Extraocular movements intact.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: No respiratory distress.     Comments: Diminished breath sounds Abdominal:     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert.    H&P 1/24/22:  CHIEF COMPLAINT: Acute respiratory failure due to COVID-19 ASSESSMENT / PLAN:   Acute hypoxic respiratory failure 2/2 COVID-19 pneumonia Vaccinated with Pfrizer on 2/5/21, 3/5/21, and boosted 9/30/21 Onset symptoms: 1/18/22 Positive test: 1/29/22 Worsening symptoms with hypoxia and admission 1/24/22 CXR shows hazy opacity in left lung compatible with COVID19 pneumonia - continue supplemental O2 (on 2L NC) - Is use, cough, deep breath, proning and activity as tolerated - supportive care with anti-pyretics, anti-emetics, anti-tussives, anti-diarrheal, and analgesics - dexamethasone (6 mg PO daily x 10 days) - remdesivir x 5 days, discussed with patient   Facial twitching Recent admit at the hospital 1/19-1/21/22 for facial twitching that spontaneously resolved EEG monitoring negative for seizure activity but high suspicion in setting of acute illness/COVID Continue Keppra (1000 mg BID) until outpatient neuro follow up   CAD, hx MI s/p RCA stents x2 (2013) Carotid artery disease s/p right CEA  Hyperlipidemia Continue aspirin/statin   Essential hypertension Continue lisinopril (2.5 mg BID)   Paroxysmal atrial fibrillation Hx MCA stroke (no residual deficits) CHA2DS2VASC = 5 for age, HTN, stroke (x2), and MI Pharmacy to dose warfarin   ANA and anticardiolipin antibody positive Antiphospholipid syndrome  Follows with rheumatology Continue hydroxychloroquine   OSA No CPAP, uses oral appliance   Hx lung adenocarcinoma s/p wedge resection RUL (2014)   Diet: general VTE ppx: on warfarin as above for a fib (high risk in COVID) Code status: FULL, per discussion with patient on admission   Patient care was reviewed with Doctor whose input is reflected above.   Disposition: admitted as inpatient for acute hypoxic respiratory failure 2/2 COVID-19 pneumonia. Anticipated LOS > 2 midnights.   HISTORY OF PRESENT ILLNESS: Patient is a 69 y.o. male with a history of coronary artery disease status post RCA stents, hyperlipidemia, hypertension, sleep apnea, paroxysmal atrial fibrillation on warfarin, prior stroke without residual deficit, and lung cancer status post wedge resection.  The patient presents to the ER with concern for worsening shortness of breath, cough, fevers, chills with known diagnosis of COVID-19.  The patient was vaccinated and boosted against COVID with last dose in September of 2021. He developed cough and tested positive on 01/19/2022.  While in line to be tested, patient developed facial twitching and ultimately was admitted 01/19 through 1/21 at the hospital.  He was not hypoxic.  EEG was negative for focal seizure activity but he was started on and discharged home on Keppra 1000 mg twice daily until outpatient neurology follow-up.  Since returning home, the patient has had no further facial twitching.  This morning, he woke up with chills, rigors, fatigue, generalized weakness, and worsening cough with shortness of breath.  He had 1 episode of vomiting.  He denies change in taste/smell, no abdominal pain or diarrhea.  He presented to the ER for further evaluation.      In the ER, patient had T-max 99.8° F, tachycardic to 102, tachypneic, and hypertensive to 213/84.  Patient was satting 88% on room air and improved to 94% on 2 L nasal cannula.  CMP and complete blood count remarkable for stable renal function creatinine 0.9, slightly elevated bilirubin 1.2, no leukocytosis, stable hemoglobin.  BNP not significantly elevated.  Chest x-ray showed left lung base hazy opacity consistent with COVID-19 pneumonia.  Patient was given home dose lisinopril as well as hydralazine 10 mg IV with improvement in blood pressure.  He was started on dexamethasone 6 mg. The patient was admitted to Internal Medicine for further evaluation and treatment of acute hypoxic respiratory failure due to COVID-19 pneumonia. Review of Systems Constitutional:  Positive for appetite change (decreased), chills, fatigue and fever. Negative for unexpected weight change.  HENT: Negative for congestion, rhinorrhea and trouble swallowing.  Respiratory:  Positive for cough and shortness of breath. Negative for wheezing and sputum production.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Positive for vomiting (one episode PTA). Negative for nausea, abdominal pain, constipation, diarrhea and trouble swallowing.  Genitourinary:  Negative for difficulty urinating and dysuria.  Musculoskeletal:  Negative for back pain.  Neurological:  Positive for light-headedness, tremors (facial twitching, resolved since 1/20) and weakness (generalized). Negative for headaches and numbness/tingling.  Psychiatric/Behavioral:  Negative for anxiety.  Skin:  Negative for rash and wound.   OBJECTIVE: BP 168/68  | Pulse 103  | Temp 99.8 °F (37.7 °C) (Oral)  | Resp 25  | SpO2 94%    Physical Exam Constitutional:      Appearance: He is diaphoretic.     Comments: Pleasant but ill-appearing elderly gentleman, lying in bed comfortably.  No distress.  Wife present and supportive at bedside.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Comments: Speaking in full sentences, slightly labored breathing.  Coarse rhonchi left lower lobe. Abdominal:     General: Abdomen is flat. Bowel sounds are normal.     Palpations: Abdomen is soft.  Musculoskeletal:        General: No signs of injury.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm.  Neurological:     General: No focal deficit present.     Mental Status: He is oriented to person, place, and time. Mental status is at baseline.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.