Age: 85.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Upper gastrointestinal haemorrhage, White blood cell count normal
Clinical narrative: Hospitalized (9.21.21);  COVID-19 positive (9.21.21);  Fully Vaccinated  HISTORY OF PRESENT ILLNESS: Pt is a 86 y.o. female with a past medical history of recent stroke, recurrent GI bleeding, HTN, AAA, hx of MI, hypotension, and rectal cancer. She presents today with worsening cough and rectal bleeding  . Secondary to patient's recent stoke, she is aphasic and unable to communicate a history or ROS. Daughter is present and able to assist with history. Daughter states that since she was discharged on 9/18/21, patient has developed a cough that has been progressively worsening. Patient did receive her COVID vaccine. She did notify the facility of this and requested a CXR for concern of aspiration pneumonia, although she is unsure if the x-ray was completed. In addition to her cough, daughter notes that staff has been noticing blood per rectum that started today (9/21/21). She denies noticing any fevers/chills or episodes of vomiting.    Patient was recently discharged from the hospital on 9/18/21 for an acute left MCA stroke with residual right-sided hemiparesis. She was started on dual antiplatelet therapy with ASA and Plavix with known risk of recurrent bleeding ,  NJ tube was placed. Prior to this, patient was admitted on 8/31 for treatment of an upper GI bleeding, where she received a 2U transfusion then asa an plavix held .  Pt presented to the ED on 9/21/21 for increased coughing with possible aspiration, as well as melena/maroon stools . On initial presentation, patient was slightly hypotensive and tachycardic. Basic labs were performed which revealed a hbg of 8.7 slightly down from most recent of 9.6 , Na2+ of 124, Ca2+ of 7.5, and mildly elevated AST/ALT. COVID test was positive which is a new finding . No hypoxia observerd  CXR was performed and revealed right upper lobe airspace disease, suspicious for pneumonia.  ASSESSMENT / PLAN: * GI bleed Assessment & Plan - Suspect upper GI bleed. Melena/maroon stool  noted by ED staff. Positive occult testing. History of GI bleeds requiring transfusions. Recently admitted 8/31 for upper GI bleed and 2U transfusion.  - EGD performed on 5/22/21 revealed a large hiatal hernia and minor erosions. Colonoscopy performed 9/2/21 friable tissue and scattered diverticula.    - Initial hbg of 8.7 and hct 26. Down from Hbg of 9.6 on 9/17/21.  - Trend H&H's q 6 hours. Transfuse if Hbg < 7.  - IV Protonix  - Obtain type and screen.  - NPO diet.  - Hold ASA/Plavix. Avoid NSAID  Use.  - Frequent vital sign monitoring  - Establish IV access x2  Gi consultation prn  Pneumonia due to COVID-19 virus Assessment & Plan - COVID pneumonia vs. Aspiration pneumonia?: Normal WBC, procalcitonin WNL, and mildly elevated AST/ALT are consistent with COVID pneumonia over aspiration.  Being at high risk for aspiration and infiltrate in right upper lobe will tx with Rocephin / azithromycin for now  - Sxs onset ~ 9/18 with (+) test on 9/21/21.  - CXR performed in ED reveals right upper lobe airspace disease, suspicious for pneumonia.  - Patient is not currently hypoxic on room air, therefore is not a candidate for Remdesivir or steroid treatment.  - Patient is a candidate for MAB treatment , covid team contacted at tx ordered  - Trend d-dimer, CRP, and CMP's.  - Maintain SpO2 > 89%. Supplemental oxygen as needed.  - Continuous pulse ox and tele monitoring  - PRN antitussives. All medications via J tube  Acute CVA (cerebrovascular accident) (HCC) Assessment & Plan History of on  9/10: Acute left MCA distribution infarct involving the left corpus striatum and left frontal lobe.  - Residual right-sided hemiparesis and aphasia.  - Hold ASA and Plavix secondary to suspected GI bleeding putting at increased risk of recurrent cva