Discharge Provider: MD Primary Care Provider: DO Admission Date: 3/2/2023 Discharge Date: 3/10/2023  PRESENTING PROBLEM: Acute respiratory failure with hypoxia  Acute on chronic respiratory failure with hypoxia  COVID-19  COVID-19 virus infection    HOSPITAL COURSE: Patient is a 92 y.o. female with PMH significant for T2DM, HLD, breast cancer stage I s/p XRT/lumpectomy, MVP, intermittent vertigo, glaucoma, depression who presented to ED via EMS on 3/2/23 after unwitnessed fall with head injury. Pt did not recall the fall. States that she had been walking and then woke up on the floor. Pt did hit left frontal region on floor and has large contusion without laceration. Denies any past falls or syncope. In ED, pt became hypoxic in the 80s requiring 4L O2. Pt has had a runny nose the past 3 days and husband tested positive for COVID on 2/28 and has been at hospital. In ED, labs significant for mild hyponatremia and positive COVID PCR. CTH and CT spine negative for acute process. CXR and CTA showing bilateral lower lobe atelectasis. Pt admitted under general medicine for further management .   Patient's acute hypoxic respiratory failure was attributed to COVID-19 infection. Patient does not use supplemental oxygen at baseline, requiring 2-4 L O2 via nasal cannula at admission. CT angiogram of chest negative for PE. LE doppler US negative for DVT. CXR showed blunting of the posterior costophrenic angles consistent with atelectasis or small pleural effusion, as well as mild linear opacity in the left mid lung consistent with atelectasis versus scar. Started remdesivir 5 day course (EOT 3/7) and dexamethasone 6 mg daily. Patient intermittently able to wean back to room air, but returned to oxygen, frequently overnight. Labs with elevated CRP and d-dimer, which were slowly down trending. Pulm rehab evaluated prior to discharge and recommended 2L NC O2 with activity. She was set up with home oxygen. She was prescribed dexamethasone to complete 10 day course.   EKG at admission showing NSR with LAD, QTC 431. Pt with new onset bradycardia with HR down to high 20s/30s-40s on tele starting 3/4 with concern for some contribution from her steroids. Echo 3/4 with LVEF 65%, no effusion or wall motion abnormality, but some poor windows. Consulted EP cardiology- briefly reviewed tele 3/5 and noted sinus bradycardia with some escape beats. Given pt remained stable. Stated no current need for intervention. Once clinically improved from her COVID, could consider transfer for EP evaluation for possible pacemaker. However, patient went into new A fib with ongoing bradycardia. Cardiology consulted and recommended transfer on 3/6 for more urgent EP consultation and evaluation for pacemaker. EP evaluated the patient, ultimately placed pacemaker on 3/9. She was started on daily metoprolol XL, and recommended to follow up in EP clinic, appointment made for 3/15.    Patient also had some mild hyponatremia at admission, which resolved with gentle IV fluids (NS at 100 ml/hr). Her electrolytes were monitored and supplemented as needed. She had worsening altered mental status/metabolic encephalopathy. UA ordered at admission but not obtained until 3/4: noted large LE, 55 WBC, 13 RBC, many bacteria. Urine cx 3/4 now growing >100k E coli. Patient completed 5 days of ceftriaxone and her mentation remained at baseline thereafter.    PT/OT evaluated and recommended discharge back home to assisted living with assistance, HHC, PT/OT. Pt had planned discharge on 3/9 but unfortunately was orthostatic with standing/ambulation. BB was discontinued and ted hose applied. Patient felt improved and ready for discharge back to assisted living on 3/10. Home oxygen set up and family provided transport.