Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Anion gap increased, Anticoagulant therapy, Bacteraemia, Bladder catheterisation, Blood creatine phosphokinase increased
Clinical narrative: INTERVAL SUMMARY 1/30/2022 Patient had not been heard from for several days so his cousin went to check on him and found him sitting in feces and altered.  For EMS, patient had acute hypoxic respiratory failure with sats in the 70s, was tachy to the 120s, tachypneic to the 50s.  In the ER, he was found to have a WBC of 19.2, AKI with a Cr of 8.51,  rhabdo with a CK of 5500, a decubitus ulcer and blood sugars of >500 with anion gap of 25 but without ketones in urine.  Infectious w/u done revealed  Positive blood cultures growing proteus - as was cx from his decubitus ulcer,  possible PNA  and perianal skin thickening w/o evidence of abscess on CT C/A/P and COVID + screen on 1/26 with + NARES MRSA swab. He required pressors for one day (stopped 1/27) and his D-dimer was >35. No PE study could be done due to his renal function. Unable to be on full anticoagulation due to need GI bleed.     ASSESSMENT This is a 70 yo w/ reported PMHx of DM, HTN, gout, RA who presented to the ED after being found altered by his cousin with feces around him. Found to have AGMA, likely some DKA with blood sugars >500, mild rhabdo, sepsis, anemia, severe AKI, very elevated D-dimer, hypernatremia and COVID.      PLAN Septic shock Source via buttock cellulitis vs CAP COVID PNA with acute hypoxic respiratory failure  Proteus bacteremia secondary to decubitus ulcer On admission, patient had acute hypoxic respiratory failure with sats in the 70s for EMS, was tachy to the 120s, tachypneic to the 50s, had a WBC of 19.2, and AKI with a Cr of 8.51 with rhabdo, a decubitus ulcer and blood sugars of >500.  Infectious w/u done revealed  Positive blood cultures with proteus as was cx from his decubitus ulcer,  possible PNA  and perianal skin thickening w/o evidence of abscess on CT C/A/P and COVID + screen on 1/26 with + NARES MRSA swab. He required pressors for one day (stopped 1/27) and his D-dimer was >35. No PE study could be done due to his renal function. Unable to be on full anticoagulation due to need GI bleed.   -Abx per ID: on cefepime and vancomycin, pharmacy dosing.  -stress dose steroids given chronic prednisone hx, 100mg hydrocortisone q8h and surgery today. - EGS consult for sacral wound, POD#1 s/p debridement, wound cx pending - heparin q8hrs-- holding d/t melena and need for transfusion. Resume as early as possible.  - f/u urine, blood cxs, wound cultures    Acute renal failure Rhabdomyolysis Hypernatremia CK was 5,579 on admission Unknown baseline, on admission Cr >8. UOP minimal. Likely multifactorial with DKA, dehydration, sepsis and rhabdomyolysis playing a role. Foley placed. No obstructive process seen on CT A/P. Hyaline casts on UA. Improved Cr and UOP with bicarb containing fluids and hypotonic fluids.  -- Nephrology consulted, appreciate assistance -- D5W with ongoing hypernatremia, nurse to alert hospitalist if this stops as it is creating hyperglycemia which is being treated.  -- follow BMP, change to daily     Metabolic acidosis w/ elevated anion gap, resolved  Lactic acidosis, resolved Likely diabetic ketoacidosis DM 2 Pt with limited hx/background, however known hx of DM, glucose >500 on EMS arrival. Started on insulin gtt in ED, transitioned off 1/27. PTA was on  metformin 500mg daily, losartan 100 daily and bicarb. -- Hgb a1c is pending.  -- lantus 15 units q day glucose -- On D5w today for hypernatremia, but still NPO for surgery today.   --Continue Sliding scale for now and will adjust when not NPO and feeding has been determined.   -- follow electrolytes. Anion gap closed   Acute metabolic encephalopathy Secondary to above. Admit CT negative for obvious acute pathology. - zyprexa PRN IM d/t poor IV access   Normocytic anemia Melena  Likely multifactorial.  - iv PPI bid  - trend hgb q6h - Transfusion today prior to surgery.  Conditional transfusion for Hgb < 7 - monitor stool output  - GI consulted but will wait until after surgeries and other issues resolved.  Will follow.   Troponin elevation Likely type II in setting of above, EKG w/o concerning ST-T changes.    hx of gout hold allopurinol  HTN hold PTA losartan, amlodipine, metoprolol .  BP elevated in setting of GI bleed.  Labetalol PRN ordered for sbp >180. Tomorrow can resume amlodipine with hold parameters.  RA hold  PTA methotrexate and prednisone 10mg daily.  On stress dose steroids for surgery and covid. O2 improving.  HLD hold PTA statin given rhabdo, resume when able to tolerate PO