Age: 55.0
Sex: M
Vaccine: COVID19
Symptoms: Vomiting, Weight decreased, White blood cell count decreased
Clinical narrative: Currently admitted at (2) inpatient admission .  H & P: Patient is a 55 y.o. male with a history of liver cirrhosis due to hep C status post treatment, Crohn's disease status post colostomy, substance abuse in remission on Suboxone, depression with anxiety, and migraines who presents to the ER with 4-5 day history of inability to urinate, as well as fevers, chills, myalgias, he T. patient was vaccinated against COVID-19 with 2 doses of Pfizer vaccine in April this year.  He lives at home with his elderly mother and great niece who have had upper respiratory symptoms for the past few days as well.  Patient denies prior history of urinary retention or enlarged prostate.  He denies flank pain, urinary incontinence, hematuria, dysuria.  He has been trying to hydrate at home, drinking 5 bottles of water every day.  He has been compliant with his other medications including Bumex.  He has noticed increased loose stools from his ostomy despite his normal regimen of fiber and Imodium.  Patient has had very poor oral intake due to worsening nausea with intermittent vomiting.  Patient endorses 25 lb weight loss since May of this year.  Currently, patient complains of severe migraine headache with nausea and photosensitivity.  He typically takes Imitrex at home for code of therapy but has not yet taken that today.   In the ER, patient was febrile 101.5 F, not tachycardic, or tachypneic.  Blood pressure soft 99/57.  O2 sat 92% on room air.  Patient tested positive for COVID-19 and received monoclonal antibodies.  Patient had significant body aches and received Robaxin, Haldol, and dilaudid IV.  Nausea not improved with Zofran.  He received 2 L IV hydration.  Labs showed AKI with creatinine 1.69, GFR 44 down from baseline creatinine 1.0.  Complete blood count with acute on chronic pancytopenia, WBC 3.3, hemoglobin 11.9.  Platelets 21000. Foley catheter was placed with 450 mL out.  Urinalysis showed trace ketones, trace blood, hyaline casts, but no signs of infection.  CT abdomen and pelvis with IV contrast redemonstrated known cirrhosis, splenomegaly, varices, but no urinary abnormality, hydronephrosis, or obstruction.  The patient complained of ongoing migraine headache, and did not feel comfortable discharging home with AKI and urinary retention.  The patient was placed in observation with Internal Medicine for further evaluation and treatment.  ASSESSMENT / PLAN:     AKI Dehydration 2/2 poor oral intake and diarrhea on diuretic Urinary retention, ?BOO Unable to void x 4-5 days, output 450 ml with foley placement in ED Cr 1.62, up from baseline 1.0 CT AP w/contrast showed known cirrhosis, splenomegaly and varices. No urinary abnormality/obstruction. UA showed trace ketones, trace blood, hyaline casts, no concern for infection - avoid nephrotoxins, renally dose meds - received 2L IV fluid, continue 100 ml/hr overnight - continue foley for now - Urology consulted - trend renal function   COVID-19 infection Previously vaccinated x2 doses Pfizer in April 2021 Onset symptoms: 12/10 Positive test: 12/14  Monoclonal antibodies: 12/14 - not hypoxic, monitor closely - supportive care with anti-pyretics, anti-emetics, anti-tussives, anti-diarrheal, and analgesics   Migraine headache Give imitrex (50 mg now) Pt does not want migraine cocktail "that has made it worse before"   Liver cirrhosis 2/2 hepatitis C (s/p Harvoni) Hx ascites, esophageal varices, hepatic encephalopathy Follows with U of M hepatology, no current plans for liver transplant Continue home xifaxin, nadolol, PPI Hold home bumex in AKI   Pancytopenia, chronic Evaluated by hematology in the past, bone marrow biopsy, attributed to cirrhosis Trend   Hx crohn's disease s/p iliectomy with colostomy formation Surgery at facility, several subsequent intestinal blockages s/p surgery Monitor bowel function   Hx opioid abuse/dependence in remission Continue home suboxone    Depression with anxiety Insomnia Continue home xanax nightly and seroquel   Unintentional weight loss Down > 25lbs since May this year Nutrition consulted   Diet: general with 2g Na restriction VTE ppx: lovenox subq (HIGH risk in COVID) Code status: FULL, per discussion with patient on admission   Patient care was reviewed with Dr. whose input is reflected above.   Disposition: placed in observation for urology eval of urinary retention and also monitoring of dehydration in COVID infection.