Age: 69.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Haemoglobin normal, Hypophagia, Hypotension, Intensive care, Ischaemic hepatitis
Clinical narrative: Hospitalized (5.5-5.13.22), now in Sub-Acute Rehab; COVID-19 positive (5.5.22);  Fully vaccinated PLUS booster BRIEF OVERVIEW: Discharge Provider:  MD Primary Care Provider:  DO Admission Date: 5/6/2022 Discharge Date: May 13, 2022  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Septic shock (HCC)  HOSPITAL COURSE: Patient is a 70-year-old male with past medical history of type 2 diabetes, rheumatoid arthritis, alcohol use disorder, right BKA, peripheral artery disease, atrial fibrillation who presented to the leading emergency department for generalized weakness, decreased oral intake, and fatigue for about a week.  While in the ER he was found to be significantly hypotensive.  He was given 3 L of IV fluids, antibiotics and required norepinephrine for blood pressure support.  He was transferred to the intensive care unit for treatment of shock.  Notably in the ER he had wounds to his coccyx, right knee and evidence of previous skin infections with healing rash throughout upper and lower extremities.  He is also COVID positive.  The patient's EKG showed a QTC of 710, for this reason his home amiodarone was held.  The etiology of his prolonged QTC is unclear, it does appear he has had prolonged readings in the past but his only QT prolonging agent is amiodarone. Overall his initial presentation was concerning for sepsis.  He has a history of immunosuppression with medications to treat his rheumatoid arthritis.  He has been off these for about a month due to anemia which is also undergoing outpatient workup with Hematology, who think it may be due to bone marrow suppression.  Workup for blood loss anemia so far has been inconclusive.  Most recently on Rinvoq.   The patient's echocardiogram was not indicative of a cardiac etiology for his shock. Patient had a CT of his chest abdomen pelvis which showed right greater than left lung consolidation, atelectasis, effusion as well as a CT of his right lower extremity that was negative for signs of soft tissue infection.  He was treated with pressors, cefepime and vancomycin and fluids.  He was started on EndoTool for glucose in the 300s. The patient showed clinical improvement, and was weaned off norepinephrine on his 3rd hospital day.  Stress dose steroids were also stopped completely on this day, and EndoTool will be continued for the next 24 hours at least until glucose stabilizes and he can be switched to a basal/bolus regimen.  A repeat EKG on his stay showed a QTC of 574 ms, down from 710ms on arrival.  The patient has had no chest pain or other cardiac symptoms during this hospitalization.  The patient central line is removed, and he is stable for transition to the hospital floor. Spoke with Cardiology as well as the hospitalist regarding anticoagulation for his atrial fibrillation / COVID-19 status verses possible blood loss anemia.  Given the patient's anemia might be secondary to bone marrow suppression rather than acute blood loss, the benefits outweigh the risks for anticoagulation.  He was started on a heparin infusion.  The patient did consent to blood transfusion in the event that it is required. On 05/09, the patient is transferred from the ICU to the general floor.  Hemoglobin remained stable. He was transitioned to Eliquis before discharge.  In terms of his cellulitis, it improved significantly and he completed a course of antibiotics while inpatient. He was discharged to inpatient rehab in stable condition.