Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Pulmonary congestion, SARS-CoV-2 test positive, Ultrasound kidney abnormal, Ureteral stent insertion, Urine protein/creatinine ratio
Clinical narrative: PROGRESS NOTE 02/07/2021 The patient is an 82-year-old woman with complicated past medical history including chronic systolic heart failure (EF 40-45%), history of bilateral ureteral obstruction and bladder outlet obstruction s/p bilateral ureteral stent exchange 12/20/2021, stage I CLL taking ibrutinib, history of limited stage renal cancer s/p partial left nephrectomy in 2009, CKD stage IV (baseline creatinine around 1.7), essential hypertension, type 2 diabetes, mild dementia with agitation and behavioral disturbances, gout, neuropathy, and recent positive Covid test 1/23/2022 who was admitted to hospitalist medicine service from emergency department 2/3/2022 with mild to moderate COVID-19, Covid pneumonia.   #. COVID pneumonia  #. Moderate COVID 19: Recovering. The patient tested positive for COVID-19 1/23/2022 as a patient was screened due to recent Covid exposure.  COVID symptoms began 1/27/2022 (harsh, nonproductive cough with associated fatigue).  Portable chest x-ray on admission demonstrating vascular congestion with increased opacification to right lung field concerning for infection.  The patient's resting room air SPO2 was transiently 89%, but acute hypoxemic respiratory failure not present. Procalcitonin 0.04; however white count more elevated and more focal opacity to right perihilar lung field concerning for superimposed bacterial pneumonia. -Empiric dexamethasone 6 mg p.o. daily, discontinue 2/7/2022 as patient appears to be recovering -Taking apixaban (also for atrial fibrillation - see below)  -Continuing empiric IV ceftriaxone + oral doxycycline through 2/10/2022  -Trending inflammatory markers -As needed antitussives   #. Acute kidney injury on CKD stage III-IV:  Patient's baseline creatinine is 1.7, and the patient's creatinine was 2 on admission. The patient's acute kidney injury most likely prerenal due to dehydration; however, mild cardiorenal syndrome can't be ruled out. Cr of 2 might be patient's new baseline.  Bladder outlet obstruction ruled out. Protein/Creatine ratio > 9, nephrotic range proteinuria. Less likely cardiorenal syndrome (acute CHF) but will continue to watch closely.   -Ginger diuresis w/ IV lasix 2/7/2022  -Holding PTA oral lasix  -Trending GFR   #. Chronic systolic heart failure: Acute CHF less likely as lung findings thought to be mainly 2/2 viral and bacterial pneumonia. EDW 225 lbs, and admission weight 233 lbs. Would benefit from fluid de resuscitation since oral held since admission.  -20 mg IV lasix every 6 hours x 3 doses  -Daily weights -Strict Is and Os    #. Asymptomatic bradycardia: The patient's daughter reported that the patient has had low heart rates for at least 3 weeks.  Twelve-lead EKG demonstrating atrial fibrillation with slow response perhaps related to sick sinus syndrome. No immediate need for pacemaer -Cardiology following, recommendations much appreciated  -Holding PTA metoprolol indefinitely  -Telemetry   #. Newly diagnosed atrial fibrillation: 2/3/2022 twelve-lead EKG demonstrating slow atrial fibrillation.  The patient does not have a known history of atrial fibrillation. CHADS2VASC of at least 4. -Cardiology following  -Apixaban 2.5 mg po bid (renally dosed), initiated 2/4/2022   #. Hx of bladder outlet obstruction and bilateral ureteral obstruction: S/P bilateral ureteral stent placement 12/20/2021 and patient's daughter was told that patient's left ureteral stent high risk for occluding. 2/4/2022 renal US only demonstrating mild hydronephrosis bilaterally, acute ureteral obstruction and bladder outlet obstruction ruled out.    #. Gross hematuria:  Starting 2/7/2022, more red urine observed in foley bag. Will re evaluate for UTI. Gross hematuria most likely exacerbated by taking apixaban.  -Continue to monitor  -Consider urology consult    #. CLL:  Diagnosed stage I 6/30/2021. Patient follows w/ Dr. through  Health Center. Restarting PTA ibrutinib after discussing case w/ Dr.  IgG level WNL, no IVIG needed.    #. Complex lesion to left kidney, incidental finding: Was present on previous US 8/21/2020, actually decreased in size. Did not discuss findings with patient.    #. Essential HTN: -PTA hydralazine and imdur -Holding PTA metoprolol XL due to bradycardia    #. Leukocytosis:  Hx of CLL further exacerbated by dexamethasone.  -Dexamethasone discontinued 2/7/2022    #. Dementia w/ agitation and behavioral disturbances: -PRN seroquel, PRN haldol if not tolerating PO    #. COPD: -PTA inhalers    #. Gout: -PTA allopurinol    #. Depression: -PTA cymbalta    #. Morbid obesity:  BMI 44.99