Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Blood culture, Blood electrolytes normal, Blood lactic acid, Blood smear test normal, Blood thyroid stimulating hormone increased
Clinical narrative: Discharge Provider:  Primary Care Provider:  Admission Date: 5/2/2022 Discharge Date: May 5, 2022  PRESENTING PROBLEM: Acute respiratory failure with hypoxia (HCC) [J96.01] Sacral contusion, initial encounter [S30.0XXA] Fall in home, initial encounter [W19.XXXA, Y92.009] Hypervolemia, unspecified hypervolemia type [E87.70] COVID-19 virus infection [U07.1]   HOSPITAL COURSE: Patient is a 79 year old woman with ESRD on HD mon, weds, Friday. She took a home test and was + for covid on 5/2/22. She had fallen Sunday 5/1/22 after losing her balance. She started experiencing a dry cough on 5/1/22 as well. She didn't feel dyspneic. She then skipped her HD on Monday 5/2/22 since she didn't trust her balance. She presented with pain in bilateral lower back and hips. O2 sat was 87% in the E.D requiring 1-2L oxygen. Bnp > 59,000. CXR with bilateral opacities. Lumbar x ray with wedge shaped deformity of L1.    She remained on 0-2 L oxygen throughout her stay. SHe underwent HD on 5/3 and 5/4 (tues-weds) to catch up. Her dry weight was challenged given evidence of hypervolemia. Her Plts were 40-50. Looking back they run low / normal for the past 1 year. She has not had a work up for this that I can see. Liver and spleen us was unrevealing as was peripheral blood smear.  Vitamin levels and tsh sent and moderately elevated. TSH has always been normal prior so would continue same dose and repeat in a few weeks.    Hematology consulted and will plan for f.u. labs, office visit and discussion of bone marrow biopsy after isolation. She denied back pain on serial questioning but had some tenderness over L1 palpation and paraspinal muscles and hip pain. She will need to f.u. with ortho spine as out patient if develops pain over L1.    Her HD days changed to tues, thurs, sat for covid so she dialized again here Thursday so she wouldn't have 3 days from Wednesday to Saturday to go between dialysis. She was seen by pulmonary rehab and discharged home on 2L oxygen 24/7.   Her home metformin and estrogen was stopped, midodrine and metoprolol increased. Eliquis will need to be held until plts consistently above 50  Discharge Provider:   Primary Care Provider:  Admission Date: 5/7/2022 Discharge Date: Current Admission. Will discharge to Skilled Nursing Facility   DIAGNOSIS at time of disposition: 1. COVID-19  2. Pneumonia of both lower lobes due to infectious organism  3. Congestive heart failure, unspecified HF chronicity, unspecified heart failure type (HCC)  4. Sepsis 5. MRSA Bacteremia 6. Rapid Response 5/11/22  ED Course as of 05/07/22 1520 Sat May 07, 2022 1221 Patient is a 79-year-old woman with multiple medical problems including end-stage renal failure who was recently diagnosed with COVID returns now hypoxic and in respiratory distress.  She had IV established EN route.  Laboratory studies including CMP complete blood count and BNP are pending.  Chest x-ray will be obtained.  Patient given IV dose of Decadron.  Will also evaluate EKG and plan for hospitalization.  I suspect patient's respiratory failure is from her COVID infection. [JV] 1515 Chest x-ray is obtained showing worsening congestive heart failure versus lower lobe consolidations and pneumonia.  Patient started on IV Rocephin, azithromycin and vancomycin due to recent hospitalization.  I did not try diuresis given patient's known end-stage renal disease and dialysis dependence.  Patient relates that she was supposed to go for dialysis this morning however was too ill.  Laboratory studies are resulted in show a significant leukocytosis with a white blood cell count 15.5.  Hemoglobin 10.7.  Platelet count remains low at 41,000 one thousand.  Metabolic panel shows a BUN 20 creatinine  2.49.  Electrolytes are unremarkable.  Procalcitonin level obtained and elevated at 1.2.  Serum lactic acid level 2.0 and blood cultures are drawn and pending.  Serum troponin indeterminate at 55-significance uncertain with underlying renal failure.  Patient did show marked improvement with supplemental oxygen.  The O2 saturations were in the 90s.  Patient was the which transferred from non-rebreather mask to nasal cannula I which she tolerated well.  Patient was reviewed with hospitalist and will be admitted for further medical management.  I did conference with family members regarding my findings and my plan.  Patient and family are agreeable.  Patient in serious condition. [JV]