10/04/21 Fever or Chills  Difficulty breathing  Fatigue  10/05/2021 CARE   Cough (Primary Dx);   SOBOE (shortness of breath on exertion);   COPD with acute exacerbation (HCC); Pulmonary HTN (HCC); New onset type 2 diabetes mellitus (HCC)   ED to Hosp-Admission  Discharged   10/8/2021 - 10/12/2021 (4 days) Hospital Acute on chronic respiratory failure with hypoxia (CMS/HCC)   Hospital Problems          POA   * (Principal) Acute on chronic respiratory failure with hypoxia (CMS/HCC) Yes                 Plan      chief complaint: Worsening shortness of breath   Acute on chronic hypoxic respiratory failure secondary to COVID-19 pneumonia -Patient uses 3 LPM of O2 at baseline.  At the ED, she required 4 LPM.  She was very dyspneic at rest and on exertion.  D-dimer was elevated.  CTA chest is negative for pulmonary embolism. There is diffuse interstitial disease with mild groundglass opacity of the right lung apex that is nonspecific.  -Continue O2 supplementation.  DuoNeb 4 times a day and as needed.  Start Mucinex, incentive spirometry and OPEP.  Consult pulmonary service   Severe sepsis secondary to COVID-19 pneumonia  -Patient presented with tachypnea, blunted tachycardia due to beta-blocker and calcium channel blocker use, with respiratory source of infection and lactic acidosis.  CT chest showed diffuse interstitial disease with groundglass opacity of the right lung apex. -Start dexamethasone 6 mg once daily.  She is agreeable to start remdesivir.  Start remdesivir once daily.  Check CRP.  Procalcitonin low.  She was started on ceftriaxone and azithromycin at the ED.  Monitor procalcitonin and if it remains low, consider discontinuing antibiotics in the next 24 hours.  Follow-up blood cultures.   Lactic acidosis -Likely due to hypoxia and sepsis.  Lactic acid on admission 2.5.  Patient received a total of 1 L NS bolus at the ED.     -Addendum:   Repeat lactic acid 2.9. O2 sat 95% on 4 LPM. She is volume overloaded on exam. I think that lactic acidosis may also be due to hypoperfusion from CHF. Will give IV diuretic and monitor. Check TTE   Acute exacerbation COPD Pulmonary hypertension -dexamethasone and remdesivir as above.   DuoNeb 4 times daily and as needed.   Continue Breo inhaler.  Patient states that she uses BiPAP at night.  Will order BiPAP while admitted.  Consult pulmonary service.   Paroxysmal atrial fibrillation -Continue diltiazem, metoprolol, flecainide and digoxin.  Continue Xarelto.  Currently on sinus rhythm on my examination.  Check EKG   Intermittent chest pain -Patient states that she has intermittent chest pain but this is her baseline.  Check EKG and troponins.   Addendum: troponin 0.04 x 2. No EKG changes. Will monitor   Hyponatremia -pt had decreased appetite in the past few days but looks volume overloaded on exam.  Sodium on admission is 126.  She received a total of 1 L NS bolus at the ED.  Repeat sodium 130. She looks volume overloaded on exam. I will continue her on diuretic. Continue to monitor sodium   Bilateral leg swelling -  She has bilateral leg swelling at baseline which has worsened in the past few days.  Continue bumetanide and spironolactone.  D-dimer is elevated.  I will order ultrasound of the lower extremities to rule out DVT   Type 2 diabetes -Hold Metformin.  I will put her on insulin sliding scale while admitted.  Closely monitor blood sugars since she is on dexamethasone.  Adjust insulin dose as needed   Anxiety/depression -Continue sertraline.  She takes temazepam nightly.  She also takes lorazepam as needed.     I offered to call her family but she declined.     1. Nutrition: Consistent carbohydrate, heart healthy diet 2. VTE prophylaxis: SCD, on Xarelto 3. Disposition: Admit to 3 S. 4. Code Status: DNI but okay for CPR -discussed with patient 5. Estimated length of stay: At least 4 more day(s) 6. Time Spent: 70 minutes was spent face-to-face with the patient, greater than 50% of the time was spent counseling the patient and family at the bedside regarding treatment, medications, chart review and lab results and coordination of care.     History of Present Illness     Pt is an 50 y.o. female who presented to the ED with worsening cough and shortness of breath.  Patient has a past medical history of COPD on home O2, atrial fibrillation, pulmonary hypertension, diastolic heart failure, hypertension, anxiety/depression, type 2 diabetes.  She has chronic hypoxic respiratory failure from COPD, using 3 LPM of O2 at home.  Her symptoms started 6 days ago.  She had worsening cough compared to her baseline.  She also had worsening shortness of breath at rest and on exertion.  She has chronic bilateral leg swelling that is also worse.  She has had poor appetite.  No diarrhea or abdominal pain.  She also complains of intermittent chest pain which is usual for her.  She was diagnosed with COVID-19 on October 5, 2021 at an urgent care center.  She had an x-ray done at urgent care which showed multifocal pneumonia.  She was advised to go to the hospital but she did not want to.  She has persistent symptoms so she eventually went to the emergency department.    Patient received only 1 dose of Pfizer vaccine in January 2021.  She states that she did not receive the second dose because she thought that she had a reaction to the first dose -she claims that she had more coughing and dyspnea after first dose.     At the ED, patient was tachypneic with RR 24, she was requiring 4 LPM of O2 at the ED.  D-dimer was elevated 0.79.  CTA of the chest is negative for PE.  There is diffuse interstitial disease with mild groundglass opacity of the right lung apex that is nonspecific.  Lactic acid was 2.5.  Patient was given NS bolus 1 L at the ED.   Patient will be admitted for treatment of acute on chronic hypoxic respiratory failure secondary to COVID-19 pneumonia.  She is at high risk for deterioration given COPD and heart disease.   Review of Systems  Constitutional: Positive for activity change, appetite change and fatigue. Negative for chills and fever.  HENT: Negative for nosebleeds and trouble swallowing.   Respiratory: Positive for cough, shortness of breath and wheezing.   Cardiovascular: Positive for chest pain and leg swelling. Negative for palpitations.  Gastrointestinal: Negative for abdominal distention, abdominal pain, constipation, diarrhea, nausea and vomiting.  Genitourinary: Negative for dysuria and hematuria.  Musculoskeletal: Negative for joint swelling and myalgias.  Neurological: Negative for dizziness, seizures, syncope, facial asymmetry, speech difficulty, light-headedness, numbness and headaches.  Psychiatric/Behavioral: Negative for agitation, behavioral problems, confusion and hallucinations. The patient is not nervous/anxious.