Age: 66.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Blood lactic acid, Blood sodium decreased, Breath sounds abnormal, COVID-19, Chest X-ray normal
Clinical narrative: o ED Clinical Course Patient was seen immediately on arrival and plan of care discussed with patient and significant other at bedside.  IV will be established blood work including blood cultures and lactic acid will be obtained.  She will be hydrated in the emergency department.  We will plan for chest x-ray as well as CT head and urinalysis.  Chest x-ray is reviewed with no focal infiltrates.  Her CT of the brain does not show any acute findings.  Laboratory studies are reviewed.  Patient's creatinine today is 3.2 with a baseline of 0.7.  Sodium is 127.  Patient's lactate 1.6.  No elevation white blood cell count.  We will continue aggressive fluid hydration in the emergency department awaiting urinalysis.  Patient's troponin is 0.22 this is likely secondary to decreased renal clearance  Urinalysis is reviewed.  Findings are consistent with a UTI.  Patient will be started on Rocephin.  According to the family the patient usually requires Solu-Cortef due to her removal of her pituitary gland whenever she gets sick.  She normally gets 100 mg this will be given IV as there oral solution expired in August 2020.  Patient's presenting to the emergency department with positive criteria for systemic inflammatory response syndrome with an active infection meeting the diagnosis of sepsis.  Patient with end organ dysfunction in combination with sepsis meeting the diagnosis of severe sepsis.  Patient had blood cultures drawn, serial lactic acids ordered and received a saline bolus of 30 mg/kg based on ideal body weight.   Reexamination reveals vital signs as detailed below, heart regular rate and rhythm without any murmur, lungs diminished at bases with no wheezing, rales, or rhonchi, skin warm and dry with no mottling or rashes, pulses 2+ and equal bilaterally with capillary refill under 2 seconds, no cyanosis, no pallor, neurologic status intact.  Further sepsis care to be completed on inpatient admission.  2/20/2022 1429 Temperature:     99.3 °F Blood pressure:    123/72 Heart rate: 78 Respiratory rate: 18  I, Dr. provided critical care.  The failure to initiate these interventions on an urgent basis would likely (high probability) result in sudden, clinically significant or life-threatening deterioration in the patient's condition is acute septic state.  All critical care time is in addition to any procedures, teaching, or physician assistant work performed.  Critical care time was spent at the bedside, patient reevaluation, reviewing tests, care plan determination, and discussing care with staff, consultants, and admitting care providers in the acutely ill septic patient.  Critical care time spent was 44 minutes.  The organ systems/conditions impaired:  Infectious disease, immunology, pulmonary, cardiology, nephrology.  Contacted that Covid is positive. patient satturating well.   I discussed the case with the facility who graciously excepts this admission for further care and treatment  Admitting diagnosis Acute kidney injury UTI with severe sepsis NSTEMI secondary to decreased renal clearance COVID-19