Discharge Provider: MD Primary Care Provider:  DO Admission Date: 11/21/2022 Discharge Date: Dec 4, 2022 COVID positive 11/22/2022 PRESENTING PROBLEM: Shortness of breath [R06.02] Necrotizing pneumonia [J85.0] COVID-19 [U07.1] Acute on chronic respiratory failure with hypoxia  [J96.21]   HOSPITAL COURSE:  70 y.o. male with past medical history significant for type 2 diabetes, CHF, hypertension, severe chronic obstructive pulmonary disease, chronic respiratory failure on 3 L, AFib on Xarelto, anemia, vascular dementia, history of bladder cancer who presented to the emergency department with complaints of worsening cough and shortness of breath.  Of note, patient had recent extensive hospital admission from 9/28-11/4 for hematuria, necrotizing pneumonia and acute on chronic respiratory failure with hypoxia.  Notes from that admission were independently reviewed.  During admission, patient was found to rhino enterovirus was started on cap coverage.  Patient had worsening respiratory status and was started on diuresis and steroids for possible chronic obstructive pulmonary disease exacerbation.  Pulmonology was consulted recommended broadening his antibiotics.  CT scan was performed revealing large area of necrotizing pneumonia in the right lower lobe with increased size of large cavitary area.  Id was consulted and bronchoscopy was performed.  After bronchoscopy, patient developed worsening respiratory failure was intubated.  Cultures from bronchoscopy grew Pseudomonas.  Bronch was repeated with MDR Pseudomonas per septa bili days.  He was switched to meropenem and successfully extubated on 10/20.  Repeat sputum culture ended up growing persistent Pseudomonas which showed resistance to meropenem.  ID switched antibiotics to Zerbaxa.  He was eventually medically stabilized and was discharged to acute rehab 11/4.  Patient notes that he was discharged from rehab on 11/18.   He initially felt stable but in the 2 days prior to admission began having increasing dyspnea which prompted him to represent to emergency department for evaluation.  In  emergency department, patient was slightly tachypneic but vitals were otherwise stable.  Oxygen saturations stable on home 3 L. baseline blood work was obtained and independently reviewed.  Blood work showing normal WBC and normal lactic acid.  Troponin 35 with repeat 30.  Stable chronic anemia.  UA was obtained showing pyuria.  EKG showing sinus rhythm with nonspecific intraventricular block.  CT thorax was obtained showing persistent grossly unchanged dense consolidation of the entire RLL and large cystic area with fluid level within the RLL consolidation again suggestive of necrotizing pneumonia with intrapulmonary abscess.  Additional areas of consolidation in perihilar regions extending into the RML and RUL similar to prior.  Blood cultures were obtained.  Patient was then admitted to General Medicine for further evaluation and management.   On admission patient was continued on Zerbaxa and ID consulted.  Pulmonology consulted.  Patient placed on remdesivir and completed course.  Placed on steroids and completed 7 days.  Patient with known chronic obstructive pulmonary disease with baseline oxygen needs of 3 L.  patient had intermittent episodes of worsening breathing that resolved with short episodes of BiPAP use with quickly returning to 3 L.  per pulmonology evaluation of admission CT they note abscess present for many years and pulmonology felt radiographically there had been some improvement in the recent infection.  After discussion with Infectious Disease decision was made to finish course of Zerbaxa through 11/28/2020 to and plan on repeating CT 4 weeks after this.  Patient with past history of combined CHF initially on admission did not appear to be in significant acute exacerbation.  Daily weights monitored without significant increase however chest x-ray on repeat imaging did show some vascular congestion and repeat BMP elevated 4000.  Baseline oral Lasix changed to IV Lasix.  Patient restarted on home Farxiga.  For unclear reason Entresto was discontinued at facility.  Restarted 11/28.  Patient with physiology of severe mitral stenosis per Cardiology notation last admission.  Cardiology consulted to ensure optimal treatment in current setting.   With regards to his acute on chronic heart failure, cardiology were consulted. Continued home amiodarone, xarelto, low dose beta blocker with carvedilol. The patient was unable to tolerate Entresto secondary to hypotension. Recommended continued follow-up with regard to his cardiac conditions.    He completed IV antibitiocis for his MDR resistant pseudomonas. He had lingering leukocytosis however this is now improving, likely prolonged by the patient's last decadron dose given for his COVID pneumonia. He was taken out of severe respiratory precautions after completing isolation period for COVID.     Patient at time of discharge on home dose of oxygen. PT/OT recc. SAR. Patient expressed desire for another facility however ultimately amenable to go to accepting facility. He was discharged in stable condition.