This is a hell of a history. From the right ventricular dilatation, hypoxia, and continued GGOs on CT scan Id say that the cause is probably the lungs. The pulmonologist is going to be your best friend here. PFTs are going to be helpful
Im 34, female, 5 ft. And currently depending on the day between 209 and 223 lbs ( its weird, Ill get to that.)Day 1 Normal bp: 90/60. Weight 184 pounds 5/29/21.So back in June, I was working in a facility housing homeless individuals. During my shift, I smelled what I thought it was an electrical fire or fumes coming through or exhaust system. I discovered that folks were either cooking or smoking methamphetamine in the facility, but couldnt do more then create an incident report and narrow down where this happened.I coughed a bit, Had a headache, went outside to clear my head. Didnt think anything of it. By the end of my shift It felt weird to breathe. Like I was stuffed up. Within 48 hours I was wheezing coughing and very fatigued. COVID negative. Started azithromycin and prednisone 7 day taper.By day 4 post incident I could feel It wasnt helping. Went to the hospital. 02 was in the high 70s, I was coughing so hard. Confused. BP elevated for me 120/70s. Admitted for 4 days. 3 COVID tests (2 pcr, 1 rapid) negative. No fever this whole time. Nothing came up in sputum tests or blood work other than what they explained as inflammation.According to docs notes: patient was admitted to the hospital originally for suspicious of pneumonia based on the chest x-ray reading. In speaking to the patient, her symptom is more consistent with a asthma/COPD attack and lack the usual signs symptoms of infectious pneumonia including fever, productive cough, leukocytosis, and known sick contact. Instead, her symptom was brought about by inhaling smoke at her workplace. Patient has a history of childhood asthma for which she managed at home with rescue inhaler, patient did not have any asthma issues as an adult until exposure at her work.Therefore, after admission, she was treated for an asthma/COPD exacerbation. Antibiotics initiated on admission ( levaquin, azithromycin)to a more appropriate diagnosis. She responded well to bronchodilators, nebulizer, and oral steroid. So I finish the azithromycin, prednisone and have duoneb, and albuterol to help.CT scan showed glass opacities, right side of lungs was worse. 5th PCR test negative for COVID.06/13-I go back to the doctor 6/13. I feel worse. They tell me to give it time.06/24- return to work on light duty. No more than 4 hours a day of walking.07/03-7/23- doctors are still saying give it time. My lungs sound clear. I quit my job with the county to work from home.07/29- go into urgent care because I feel like I cant breathe. Exacerbation of symptoms. They talk about referral to pulmonologist but nothing yet. More prednisone dosepak7/30-8/15- using flutter, spirometer, albuterol and duoneb still as directed. Flutter/ spirometer every hour. Albuterol every 8 hours.Hospital admission 8/16-8/21 doctors notes*Called by nursing due to worsening hypoxia. Patient was admitted for presumed asthma exacerbation with high suspicion for COVID-19 infection. She was initially on room air with SPO2 of 90%. Since her admission, her oxygen needs has been gradually increasing. She is currently on 15 LPM oxygen mask with SPO2 95%. She is becoming more tachypneic with respiratory rate up to 36.Due to lactic acidosis of 3.9 on presentation, patient was started on normal saline at 125 mL/h. She was also started on dexamethasone for presumed asthma exacerbation with possible COVID-19 infection. She is on albuterol MDI inhaler every 4 hours and every 2 hours as needed.Vital signs: Temperature 98.7, pulse of 107, respiratory rate 36, blood pressure 114/74, SPO2 95% on oxymask.On physical exam, patient is alert and oriented. She shows signs of mild respiratory distress with increased work of breathing and tachypnea. She has decreased breath sounds with mild crackles expiratory right greater than the left. No active wheezing.Laboratory studies show white count of 18.3, hemoglobin 14.7, platelets 277. Chemistry panel within normal limits with potassium of 3.9. Magnesium low at 1.7. Lactic acid improving to 2.2 from 3.9. Procalcitonin less than 0.05. D-dimer 0.41.CTA with PE protocol per my review shows no filling defects consistent with pulmonary embolism. There are mild diffuse patchy interstitial bilaterally concerning for COVID-19 infection versus asthma related pneumonitis. No pleural effusions or focal consolidations.Acute hypoxemic respiratory failureLactic acidosisHigh suspicion for COVID-19 infection. Progressive worsening with administration of IV fluids. Improving lactic acid.Plan: -Discontinue IV fluids. -Furosemide 40 mg IV once. -Continue dexamethasone 6 mg by mouth daily for 10 days. -Continue albuterol scheduled and as needed. -Magnesium sulfate 4 g IV once to assist with treatment of possible asthma exacerbation. -Check ABG. -Continue levofloxacin. -Follow-up COVID-19 testing results. Continue precautions for now. -Escalate to high flow oxygen to decrease work of breathing.Patient is critically ill. The patient continues to have: Acute hypoxemic respiratory failure the vital organ system that is affected is the: Respiratory system If untreated there is a high chance of deterioration into: Respiratory failure, cardiac arrest, and eventually death. The critical care that I am providing today is: I performed an extensive data review and discussed care with patient. I have stopped IV fluids and started diuresis with furosemide 40 mg IV. I started magnesium sulfate IV for treatment of presumed asthma exacerbation. I have escalated oxygen needs to high flow oxygen.I get discharged from this hospital stay with 2L oxygen constantly. I get to see my doctor for follow up 9/8. They tell me again to get better first. Then well look at respiratory therapy and pulmonologist and physical therapy long term. I talk to them about my weight gain and my puffy face. They say its common with steroids. I can self monitor for oxygen use.9/17 develop vertigo, confusion, nausea and vomiting. Diagnosed with colitis. COVID negative. Urgent care visit. No longer on oxygen but still exhausted.9/25- diagnosis sinusitis, vertigo from left ear infection. Lungs clear. COVID negative10/5- vertigo doesnt go away. Given meclizine. COVID negative10/17- patient noted to have slightly elevated blood pressure likely circumstantial secondary to presenting complaint (152/90). Referred to primary care physician for further evaluation.Medical Decision Making: CT temporal bones show some fluid within the left mastoid. Slight elevation of white count. Patient also has an abnormal dilatation of the right lateral ventricle on CT of her head. This is concerning in light of her ongoing nausea vomiting and vertigo over the last several weeks. Discussed with pharmacy and placed on antibiotics to cover for possible mastoiditis and discussed with hospitalist for admission for further evaluation and treatment of this ongoing vertigo and abnormal CT head. Admitted in guarded condition.10/17- COVID positive. Test results received after discharge. 10/18. 10/21 tests negative for COVIDWeight gain from June to October 21 is from 184 pounds to 222.October 27- pcp follow up after quarantine. Currently 231 pounds. BP is 148/86.Doc notes History of Pneumonia, RecurrentRecurrent pneumonias with recurrent hospitalizations Exposure to methamphetamine at work at shelter - ended up with ground glass opacities on imaging. Tested multiple times for covid, negative at that time. Has had persistent fatigue, lightheadedness, loss of energy Positive for Covid 10 days agoWeight GainGained 30 pounds since September. Has had recurrent doses of steroids with recent infections. Orthopnea Has had decreased appetite and is not eating much at all. When she does eat a lot, feels need to vomit.HypoxiaDesaturations throughout hospitalizations, was discharged on home oxygen which she was able to wean down, but does still have hypoxia when she sleeps and exertion. Concerned for sleep apnea.VertigoRecurrent episodes of vertigo especially after recent illnesses Reports that she is occasionally awoken by vertigo and hot flash symptoms. Repeat evaluations for the same - does have history of CP, recent finding of R ventricle enlargement on MRI. Some benefit with Meclizine, but has had abnormal associated symptoms including confusion, word finding difficulty. Continued to say istory of pneumonia, recurrent Suspicion for initial covid infection with negative test causing initial ground glass opacities As these are consistent with many other etiologies and she has significant other symptoms (fatigue, weight gain, hair loss, vertigo with normal TSH) will consider other etiologies ANA, RF, anti-CCP for evaluationWeight gain TSH normal in the past, so has never reflexed to T4 and T3 - will measure these Autoimmune evaluation as elsewhereHypoxia Pulmonology evaluation,possible covid long-hauler symptoms, possible other causes of groundglass opacities Sleep study and general PFTsCurrently taking : Claritin albuterol Flonase every day. Meclizine as needed. I think they help.I KNOW THIS IS A LOT. I m sorry thank you for even reading this but I wanted to be thorough.How can I advocate for myself further? What can I ask about? Any additional testing you would suggest? I dont feel like a person anymore. If I eat, clean my kitchen and walk the kids to school it takes everything I have.