Hospitalized (12.25.21 - still admitted currently); COVID-19 positive (12.24.21);  fully vaccinated PLUS Booster - J& J H&P: Attestation signed by, MD at 12/25/2021  2:18 PM I have seen and examined patient independently. Discussed with house staff. I agree with the subjective and physical exam findings and assessment and plan.   Patient feels much better this am. CPAP will be changed to BiPaP this am. Agree with steroids, lasix,antibiotics and remdesivir for now.     -  MD, Attending Physician, Im/hospitalist.    Expand All Collapse All     Hide copied text  Hover for details   CHIEF COMPLAINT: Acute respiratory failure with hypoxemia       Assessment/Plan     ASSESSMENT / PLAN:   Patient is a 60 y.o. female with a past medical history of morbid obesity, OSA, COPD on 2L continuous and 4L at night, chronic diastolic heart failure, insulin-dependent T2DM, CKD3, Afib/flutter on Eliquis, and hypothyroidism who is admitted for acute respiratory with hypoxia and hypercarbia secondary to likely mixed COPD and diastolic heart failure exacerbations in the setting of COVID-19 infection.     Acute respiratory failure with hypoxia and hypercarbia COPD exacerbation Chronic diastolic HF exacerbation COVID-19 infection Patient symptomatic with main symptom of shortness of breath starting 12/20, developed mild viral symptoms, and tested positive in ED 12/24. CXR not consistent with pure COVID-19 pneumonia. Likely COVID-19 triggered COPD and chronic diastolic heart failure exacerbations, as evidenced by fluid overload and expiratory wheezing on examination, as well as edema and pulmonary vascular congestion on CXR. Cannot rule out bacterial superinfection as well given opaque L middle lung finding on CXR, leukocytosis to 15 at OSH, and procalcitonin elevated at 0.98. Last echo in September EF 60-65%, no RWMA. Plan: o COVID-19 infection: ? Solumedrol 40 mg q8h ? Remdesivir ? Home Eliquis for anticoagulation o COPD exacerbation: ? Duonebs q4h scheduled ? Trend VBGs q6h for hypercarbia o Chronic diastolic heart failure exacerbation: ? Given lasix 40 mg IV (prescribed torsemide 20 mg daily outpatient) ? Continue home lisinopril ? Started imdur 10 mg, consider adding hydralazine prn for SBP >180 ? Echo o Bacterial superinfection? ? Sputum cx ? CAP coverage with Azithro/Rocephin ? S pneumo, legionella urine Ag   Paroxysmal atrial fibrillation/atrial flutter Currently in sinus rhythm.  Plan: - Continue home amiodarone, diltiazem, eliquis   Hypothyroidism Plan: - Continue home levothyroxine   Type 2 DM, insulin-dependent Last A1c 6.7% two months ago. Home regimen: tresiba 30 units bid + lispro with meals/bedtime. Plan: - Lantus 10, LDC     Essentials: Code Status: FULL DVT prophylaxis: Lovenox Diet: NPO Dispo: Continue inpatient care for respiratory failure   This assessment and plan was discussed with an attending physician, Dr. For further information see attending attestation.   MD PGY-1, Neurology Available on database         Subjective     HISTORY OF PRESENT ILLNESS: Patient is a 60 y.o. female with a past medical history significant for morbid obesity, OSA, COPD on 2L continuous and 4L at night, insulin-dependent T2DM, CKD3, Afib/flutter, and hypothyroidism who presented to OSH with 4-5 days of shortness of breath, fatigue, body aches, and dry cough. She denied fevers, abdominal pain, nausea, dizziness, lightheadedness, syncope, chest pain, or chest pressure. She endorsed diarrhea for 2 days. OSH workup notable for respiratory acidosis 7.19 with pCO2 81, which corrected after BiPAP to pH 7.31 with pCO2 64, bicarb 29. Cr 1.4 (baseline 1.5), Troponin 0.04->2, BNP 315, Lactic acid 2.3, leukocytosis 15 with left shift, UA without signs of infection. CXR once transferred to facility showed congested pulmonary vasculature and perihilar haziness consistent with CHF or edema, as well as left midlung opacity which could be atelectasis versus pneumonia. VBG on arrival to facility showed pH 7.32, pCO2 68.8.    Patient Active Problem List Diagnosis ? Acute respiratory failure  ? Acute respiratory failure with hypoxemia  OBJECTIVE: BP (!) 182/78  | Pulse 96  | Temp 36.4 °C (Oral)  | Resp 26  | Ht 1.575 m  | Wt (!) 140 kg  | SpO2 100%  | BMI 56.45 kg/m²  FIO2 (%): 36 % Physical Exam Constitutional:      Appearance: She is obese. She is ill-appearing. She is not diaphoretic.  HENT:     Head: Atraumatic.     Nose: No congestion.     Mouth/Throat:     Mouth: Mucous membranes are dry.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Tachycardia present.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard.    Pulmonary:     Effort: No respiratory distress.     Breath sounds: Wheezing (expiratory) present.  Chest:     Chest wall: No tenderness.  Abdominal:     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: Edema present.     Left lower leg: Edema present.     Comments: 3+ pitting edema bilaterally, chronic venous stasis changes and scarring to skin of bilateral shins.   Skin:    General: Skin is dry.     Capillary Refill: Capillary refill takes 2 to 3 seconds.     Coloration: Skin is not jaundiced.     Findings: Rash (redness, odor, and skin breakdown between pannus folds) present.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.     1/4/22 Progress note: Attestation signed by, MD at 1/4/2022  4:40 PM I have personally interviewed and examined the patient on 1/4/2022. Management was discussed with the resident I agree with the documented findings and plan of care in his note.   Brief exam:  General- no acute distress Head- Normocephalic and atraumatic Cardiac- regular rate and rhythm, no murmurs Respiratory- clear to auscultation bilaterally Abd- soft and not tender, not distended Skin- no rash Neuro- alert and oriented, no new focal deficits Psych- cooperative, appropriate     Brief history and medical decision making:  Patient is a 60 yo woman with hx of morbid obesity, OSA, COPD on 2L, Chronic HFpEF, DM2, Afib/flutter on Eliquis presented with acute on chronic hypercarbic and hypoxic resp failure from acute exacerbation of COPD caused by COVID-19 infection and acute on chronic diastolic heart failure. Will d/c home BIPAP. Completed remdesivir and empiric CAP coverage, 5 days. Prednisone taper thru 1/13. Diuresed well. Chronic right heel wound which was seen by Wound Care. PT/OT recommending SAR.       Admit Date: 12/25/2021        Chief Complaint Acute respiratory failure with hypoxemia secondary to COVID-19    Assessment/Plan Patient is a 60 y.o. female with a past medical history of morbid obesity, OSA, COPD on 2L continuous and 4L at night, chronic diastolic heart failure, insulin-dependent T2DM, CKD3, Afib/flutter on Eliquis, and hypothyroidism who is admitted for acute respiratory with hypoxia and hypercarbia secondary to COPD and possible diastolic heart failure exacerbations in the setting of COVID-19 infection.   Acute on chronic respiratory failure with hypoxia and hypercarbia COPD exacerbation Chronic diastolic HF exacerbation COVID-19 infection Patient symptomatic with main symptom of shortness of breath starting 12/20, developed mild viral symptoms, and tested positive in Allegan ED 12/24. CXR not consistent with pure COVID-19 pneumonia. Likely COVID-19 triggered COPD and chronic diastolic heart failure exacerbations, as evidenced by fluid overload and expiratory wheezing on examination, as well as edema and pulmonary vascular congestion on CXR. Cannot rule out bacterial superinfection as well given opaque L middle lung finding on CXR, leukocytosis to 15 at OSH, and procalcitonin elevated at 0.98. Echo 12/25 EF 60% no rwma Plan: o COVID-19 infection: ? Prednisone 30mg, will taper 10mg every 3 days. Ends 1/13 ? Home Eliquis for anticoagulation o COPD exacerbation: Duonebs q4h scheduled ? BiPAP nightly. Pulm Rehab c/s, will coordinate going home with BiPAP. o Chronic diastolic heart failure exacerbation: ? Lasix 40 once PO daily due to BUN/Cr increasing over the course of hospitalization. ? Continue home lisinopril ? Echo EF 62%    Right Heel pressure ulcer Previously known pressure wound on right heel. Was covered with SCDs. Granulation tissue intact with small area of open, weaping wound. Patient complains of pain on wound.  Plan: - wound consult, hydrocolloid to be changed every 3 days.     Paroxysmal atrial fibrillation/atrial flutter Currently in sinus rhythm. 1 episode Afib RVR 12/26 <1 hour self converted to NSR Plan: - Continue home amiodarone, diltiazem, eliquis, propanolol   Hypothyroidism Plan: - Continue home levothyroxine   Type 2 DM, insulin-dependent Last A1c 6.7% two months ago. Home regimen: tresiba 30 units bid + lispro with meals/bedtime. Actos on med rec. Hyperglycemia without oral intake due to steroids. Plan: -Goal glycemic control 100-180s -Steroid taper will help -Lantus 30 units daily -HDC   Diet: Diabetic DVT Prophylaxis: eliquis Code Status: full Disposition: medically stable for discharge. She is awaiting insurance auth for accepting SAR.     This patient was discussed with my attending physician, Dr. Please refer to their attestation for any additional information and changes to the plan outlined above.   MD PGY-1      Subjective: No acute events overnight. She states that she is doing well today with no complaints or concerns. States that her breathing is improving today and swelling around the same. States that her heel is not very painful today.   Review of Systems  Constitutional: Negative for chills and fever.  HENT: Negative for congestion.   Eyes: Negative for blurred vision.  Respiratory: Negative for cough.   Cardiovascular: Negative for chest pain and palpitations.  Gastrointestinal: Negative for abdominal pain, nausea and vomiting.  Genitourinary: Negative for dysuria.  Skin: Negative for rash.  Neurological: Negative for dizziness.         Objective:   BP 117/75  | Pulse 64  | Temp 36.9 °C (Oral)  | Resp 20  | Ht 1.575 m  | Wt 129.5 kg  | SpO2 100%  | BMI 52.22 kg/m²  Physical Exam Vitals reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is obese. She is not diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear. No oropharyngeal exudate.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard. No friction rub. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Rales present. No wheezing.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.     Comments: Anasarca present  Musculoskeletal:     Cervical back: Normal range of motion.     Right lower leg: Edema (improving) present.     Left lower leg: Edema (improving) present.  Skin:    General: Skin is warm and dry.     Findings: No erythema or rash.     Comments: Venous stasis changes lower extremities.   Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood and affect norma