Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Blood osmolarity, Blood potassium normal, Blood sodium decreased, Blood urea increased, Blood urea nitrogen/creatinine ratio increased
Clinical narrative: 81 Y male with a h/o obesity, HLD, prediabetes, CAD s/p stent, thrombocytopenia, GERD, LUTS who presents 1/6 with weakness, found to be COVID positive with elevated troponin, admitted for ELEVATED TROPONIN I, resolved, weakness, and found to have UTI, hospitalization c/b +FOBT c/f occult GI bleed. Hospital course complicated by bilateral subsegmental pulmonary emboli.   Pt without any urinary symptoms on admission though has had progressive weakness x 1 week with associated longstanding urinary and bowel incontinence, no neurological deficits c/f cauda equina. Afebrile and not meeting sepsis criteria despite recorded fever in EMS prior to admission. Not tachycardic, no white count, stable tachypnea in setting of mild COVID. UA with large LE, negative nitrites, >182 RBCs, >182 WBCs, 3+ bacteria c/f UTI. Began CTX 1 g daily (1/6 - 1/8), transitioned to PO Keflex (1/8) then d/c 1/9 given likely contaminant and no UTI.    Incidentally found to be COVID positive 1/6 on admission. No sick contacts. Mild cough with white sputum and weakness x 1 week but otherwise asymptomatic. Lungs with decreased breath sounds left base, no crackles or wheezes. On 1/9, new 1L NC O2 requirement. Repeat CXR with progressive bilateral opacities c/w COVID PNA. Still diffusely weak. Initiating decadron 6 mg daily and remdesivir (1/9 - 1/13).   Hospital course c/b occult GI bleed. Pt with h/o iron deficiency anemia (last iron panel 2017 with Fe 43) previously on iron supplementation. Presented on 1/6 after 1 week of weakness and a single episode of melena, with FOBT positive on 1/8 after another dark stool. Given 1 dose of IV Iron. Course further complicated by development of bilateral subsegmental PE on 1/12 as seen on CT PE. Heparin gtt started and patient was subsequently transitioned to Eliquis. Stopped for a day due to HgB<7 with no overt signs of bleeding, but did require 1 u pRBC. Eliquis subsequently restarted the following day. No further concerns for bleeding. Pulmonology was consulted as patient required escalation of O2 requirement to High Flow Nasal Cannula, received 1 dose of tocilizumab & IV steroids -- >oral steroids now finishing course of oral dexamethasone.    Patient re-evaluated by PT due to his deconditioned status and was skilled for SNF.   Overnight, 1/22 patient had 4-5 episodes of burgundy stool noticed. Patient was kept NPO and Eliquis was overnight and was prepped in case he needed a colonoscopy. Hgb/Hct remained stable throughout the entire night and morning .1/23 AM HgB: 8.8./25.8. Discussion with GI/Dr. no indication for colonoscopy at this time. Would resume Eliquis given no further indication/signs of active bleeding.     Detailed Problem list as below.   #COVID-19 PNA #Complicated by b/l small subsegmental pulmonary artery emboli  #Generaized Weakness Incidentally found to be COVID positive 1/6 on admission. No sick contacts. Mild cough with white sputum and weakness x 1 week but otherwise asymptomatic. Lungs with decreased breath sounds left base, no crackles or wheezes. On 1/9, new 1L NC O2 requirement. Repeat CXR with progressive bilateral opacities c/w COVID PNA. S/p Decadron 6 mg daily and 5 day course of remdesivir (1/9 - 1/13). Subsequently patient's respiratory status worsened on 1/13 requiring HFNC. Pulmonology consulted and patient s/p 1 dose of Toci, IV Decadron 20mg  (1/13-1/18 ) and currently on oral dexamethasone 10mg x 5 days (1/19-1/24). On 1/12, D-Dimer elevated, CT PE showed worsening scattered b/l small subsegmental pulmonary artery emboli. Discussed with Heme/Onc, started pt on heparin gtt with PLT count around 50. Discussed with patient and DDM and decision was to proceed with heparin gtt. Inflammatory markers downtrended. Given patient's improving respiratory status and no acute need for procedural intervention, patient transitioned to Eliquis 5mg BID. Eliquis 5mg BID held on 1/19 as patient's H/H was 6.9. S/p 1 u pRBC now at 8.4. After no signs of further bleeding, Eliquis resumed 1/20. Overnight, 1/22 patient had 4-5 episodes of burgundy stool noticed. Patient was kept NPO and Eliquis was overnight and was prepped in case he needed a colonoscopy. Hgb/Hct remained stable throughout the entire night and morning .1/23 AM HgB: 8.8./25.8. Discussion with GI/Dr. no indication for colonoscopy at this time. Would resume Eliquis given no further indication/signs of active bleeding. - C/w Eliquis 5mg BID - Isolation Period: 20 days (Covid + 1/6-1/25) - continue protonix 40 mg BID - optimize O2 status for goal O2 sat > 92% - daily CBC, chem 7, LFT's - PT eval: SNF for PT - SW eval for caregiver support     #Thrombocytopenia H/o thrombocytopenia with baseline plt 90s. On admission, plt 59 in setting of elevated troponin, COVID, and UTI. No signs of bleeding on exam, will CTM. Patient was seen in 12/2019 by Oncology for thrombocytopenia which was suspected 2/2 to mild myelofibrosis vs ITP. At that time decision was to monitor and not perform bone marrow bx per patient did not want it unless necessary. PLT 51 on 1/23. - daily CBC - transfuse for plt < 30 given occult GI bleed -DISCONTINUE ASPIRIN 81mg   #Occult GI Bleed (Resolved)  #Weakness #Iron Deficiency Anemia Pt with h/o iron deficiency anemia (last iron panel 2017 with Fe 43) previously on iron supplementation. Presented on 1/6 after 1 week of weakness and a single episode of melena, with bedside glove test in ED showing brown stool without any melena or BRBPR. No abdominal symptoms and no abdominal TTP. Weakness has persisted. FOBT positive on 1/8 after another dark stool. Increasing protonix to 40 mg PO BID, H pylori negative. Iron studies with Fe 16, transferrin 6, TIBC 253 c/w iron deficiency anemia, will begin tx with IV iron.  Received IV iron 300 mg x 1 on 1/9/2022 - protonix 40 mg PO BID   #Elevated Troponin, Peaked #H/o CAD s/p Stent #HLD, Obesity Pt with h/o HLD, CAD, and MI s/p DES x 1 (2014). Presents with elevated troponin 0.08 on admission, asymptomatic without chest pain, palpitations, nausea. EKG unchanged from prior. VSS. Physical exam with R 2nd intercostal systolic murmur but otherwise stable. Not meeting sepsis criteria on admission but possible that troponemia still 2/2 demand given underlying COVID disease and UTI. Trended trops to rule out ACS at this time given cardiac history and risk factors, peaked overnight 1/6 so low likelihood ACS. - continue ASA 81 mg daily  - continue PTA atorvastatin 40 mg qHS - continue PTA lisinopril 2.5 mg daily - continue PTA metoprolol tartrate 25 mg BID - cardiac diet no caffeine   #BPH - continue PTA finasteride 5 mg daily - continue PTA terazosin 8 mg qHS   #Life Care Planning Discussed goals of care with patient in ED: pt firmly DNR and DNI even if temporary trials of resuscitation and intubation are likely to reverse an underlying acute process. Previously full code, now DNR/DNI on admission. E-POLST completed.    AKI (resolved) Baseline Cr: ~0.8-1.0/ 1/23: 0.95 Differential diagnosis for patient's AKI could be pre-renal causes including dehydration and poor po intake which can be contributory as patient has been eating <50% of meals. Intrinsic causes of renal disease CIN given patient's recent CT PE on 1/12 and now 3-5 days later within time frame of expected elevation of Cr iso CIN. Post-renal obstruction less likely on the differential, patient has had no concerns with urination including dysuria or hematuria. BUN/Cr ratio>40 & FeNa: 0.2% . Suspect multifactorial etiology 2/2 to pre-renal cause + CIN.    #Hyponatremia (resolved) Na:132 (Downtrending), Serum Osm: 292, Urine Osm: 774, Urine Na: 29 Suspect 2/2 to poor po intake, SIADH in  presence of bilateral pulmonary embolism.    #C/f UTI (resolved) #Incontinence Pt without any urinary symptoms on admission though has had progressive weakness x 1 week with associated longstanding urinary and bowel incontinence, no neurological deficits c/f cauda equina. Afebrile and not meeting sepsis criteria despite recorded fever in EMS prior to admission. Not tachycardic, no white count, stable tachypnea in setting of mild COVID. UA with large LE, negative nitrites, >182 RBCs, >182 WBCs, 3+ bacteria c/f UTI. Began CTX 1 g daily (1/6 - 1/8), transitioned to PO Keflex (1/8) then d/c given likely contaminant and no UTI.    Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  COVID-19 PNA    Complications: Bilateral sub-segmental pulmonary embolism, Hyponatremia, concern for Lower GI bleed/occult GI bleed