PROGRESS NOTE 1/23/2022 ASSESSMENT & PLAN The patient 83 y.o. female, with PMH of hypertension, hypothyroidism, depression, ICM status post PCI/LAD in 2018, aortic stenosis, interstitial lung disease, LV systolic dysfunction, LV thrombus, status post right BKA due to arterial occlusion, resident at assisted living facility, admitted with acute respiratory failure, COVID-pneumonia. TTE 1/16 also shows HFrEF (30-35%) slightly worsened from prior (2019) and severe Ao stenosis w/ worsening trans-valve gradients. Improving w/ steroids and diuresis, off O2 as of 1/19. Pt has persistent weakness (like acute on chronic), hesitant to get out of bed, will very likely need higher level of care (from ALF).   Goals of care. Pt w/ significant co-morbidities, cognitive impairment, minimal f/u since 2019. To optimize medically and avoid future hospitalizations will minimally need close f/u with cardiology for her HFrEF, ?CT surgery referral for severe Ao stenosis; has no specialty follow-up since 2019, will reach out to palliative to help clarify if intensive medical cares after d/c are still consistent w/ pt's overall goals of care.  - palliative care consult, appreciate recs - DNR/DNI, plan for current medical cares, care transitions on d/c   Acute hypoxic respiratory failure Suspect combination of COVID+CHF+severe Ao stenosis - COVID management as below - CHF/Ao stenosis management as below   COVID PNA Patient diagnosed with COVID 2 weeks back per patient history.  Reports shortness of breath, cough, diarrhea for the last 2 weeks.  Patient required nonrebreather on admission, currently on 2 L of oxygen.  Patient is vaccinated with 2 shots, did not get booster yet. - imaging: CTPE 1/15 - no PE -Steroids:             - Initially on decadron, changed to Solu-Medrol 40 mg IV twice daily 1/16, 1/19 40mg daily             - prednisone 40mg daily, 1/20 -              - favor extended course/taper given h/o ILD, tentatively plan for ~ 14d of steroid therapy             - hold CellCept while on steroids - resume once steroids off -Follow inflammatory markers CRP, D-dimer - PT/OT   Leukocytosis UTI vs. bacteriuria WBC 26K on 1/21 - clinically pt unchanged, remains off O2, no fever, CRP down-trending. Suspect 2/2 steroids (did receive high dose solumedrol initially) as no clear s/o infection however will send repeat w/u and monitor, if new fever low-threshold to start abx.  - UA w/ nitrates, started empirical abx - plan for 5d therapy empirically even as UC only w/ mixed flora - BCx2, Sputum culture. Procal, MRSA nares - neg, continue to monitor   Ischemic cardiomyopathy status post PCI/LAD in 2018 HFrEF 30-35% 1/2022 (prior 40-45% 2019) Severe Ao stenosis HTN HLD PTA medications aspirin,  Plavix, Coreg, lisinopril, statin. On admission hypoxic, thought not to be in acute exacerbation however BNP 1,400 w/ normal renal function. On 1/16 TTE w/ worsened EF and severe Ao stenosis w/ worsened trans-valve gradients from prior (2019). Per chart review, last echocardiogram showed EF 45%, severe low-flow gradient aortic stenosis in 2019; no follow-up since. Discussed w/ pt's daughter as well; it seems pt has been somewhat reluctant to follow with medical cares, this is further complicated by COVID. Suspect current presentation 2/2 some degree of CHF exacerbation. Diuresing and cards consult. medical/surgical mgmt if compatible w/ overall goals of care. - continue PTA meds - cardiology consult, appreciate recs - lasix : 10mg 1/17, 20mg 1/18 and 1/19; 10mg PO 1/20, to 20 mg 1/21 - outpatient f/u for consideration of Ao stenosis intervention if compatible w/ goals of care - daily weights - strict I/Os as able - pt is incontinent   Diarrhea. Stable/resolved. Reported PTA, possibly 2/2 COVID, monitor.    H/o Interstitial lung disease, not in flare H/o Jo1+ SSA+ polymyositis/anti-synthetase syndrome On Cellcept PTA, last seen in 2019 by Dr., no f/u since. - hold cellcept while on steroids - re-establish care with rheumatology asap outpatient    H/o hypothyroidism -Continue PTA levothyroxine   H/o right BKA due to arterial occlusion in 2018 Noted