Age: 82.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Presyncope, Respiratory syncytial virus test negative, SARS-CoV-2 test positive, White blood cell count increased
Clinical narrative: Admitted to hospital for COVID HISTORY OF PRESENT ILLNESS: Patient is a 83 y.o. male with PMH of HTN, CAD, CVA, IFG, h/o alcohol dependency with liver cirrhosis, rectal cancer s/p low anterior resection in 2011, bicytopenia and leukocytosis, recurrent blood in stool, urinary retention with suprapubic catheter in place who presents with increasing fatigue, weakness, presyncope and blood pooling in depends.    Patient reports there has been quite a few family members recently d/w COVID-19. States he started feeling weak and fatigue since a week ago. He has also noticed a persistent dry cough around the same time. Around midnight, he feels as though he would pass out after going to the bathroom, which made press the life alert button. He also endorses dark tarry stools for past 3 days but has only noticed significant maroon blood pooling in depends since being in the ER. Appetite has been "so so", states he drinks mainly diet pepsi and eats microwavable meals. Occasionally his daughter in law would bring meals over to his house.  Patient admits to chronic bilateral foot edema.  Denies suprapubic pain or discharge from suprapubic catheter.  Denies noticing blood or dark colored urine.  Patient denies any recent fever, chills, sputum producing cough, headache, vision changes, nausea, vomiting, hematemesis, chest pain or pressure, palpitation, shortness of breath, wheezing, abdominal pain, weakness or numbness of the extremities.  Patient has been taking NyQuil for symptoms.  Otherwise denies current NSAID use, tobacco or alcohol use.  Patient does have a h/o alcohol dependency in the past with CT imaging obtained in 2011 suggestive of liver cirrhosis.    Of note, patient was seen by Hematology in May of 2021 for evaluation of by cytopenia and leukocytosis with plan for CT A/P to evaluate for hematochezia which was concerning for recurrent rectal cancer.  However it seems patient has not obtain CT imaging or follow-up with Hematology since then.  It was noted in Hematology note that if rectal cancer recurs, patient would want to forego systemic treatment or chemotherapy. However, when I talked to patient, he also reiterates the reason he did not get the CT scan was because he was not going to pursue treatment if cancer recurs.    In the ED, vital signs 146/65, 72 bpm, 97.7F, 96% on RA. Positive orthostatic vitals. Work up significant for bicarb of 19, calcium 7.8, BUN 42, creatinine 1.87 with EGFR 33 (baseline creatinine 1.0). EtOH < 10. INR 1.5, PTT 45. Hemoglobin 6.5 (9.6 in May), WBC 35.3k, platelet 77k. ECG NSR with 1st degree AVB, w/o ST segment changes or TWI. CXR showed stable small b/l pleural effusions. Negative for influenza A/ B and RSV. Unfortunately COVID-19 PCR returned positive. BCx x2 obtained. Patient is receiving 2 units of pRBCs. Hematology was consulted in ER and recommended vitamin K and platelet transfusions. GI was also consulted. Of note, patient is on Plavix for secondary stroke prevention since CVA in 2009.   EGD 08/02/2011 - for hematochezia and iron deficiency anemia No Barrett's esophagus Esophageal ring noted Hemorrhagic mucosa in the stomach antrum Normal duodenum   Colonoscopy 08/02/2011- for hematochezia and iron deficiency anemia 3 cm ulcerated tumor which occupied 25 - 49% of the circumference of the rectum, 8 cm from the entry site.  Pathology returned positive for invasive adenocarcinoma.