Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Blood bicarbonate, Blood chloride decreased, Blood glucose increased, Blood lactic acid, Blood pH normal
Clinical narrative: ED to Hosp-Admission Discharged  9/8/2021 - 9/22/2021 (14 days)  Last attending ? Treatment team Acute respiratory failure with hypoxia  Presenting Problem/History of Present Illness/Reason for Admission Shortness of breath Hypoxia  Elevated troponin DKA, type 2, not at goal Hospital Course         Patient presented to the hospital on 9/9 with weakness, ambulatory dysfunction and shortness of breath.  Patient was found to have new onset oxygen requirement and lab work was concerning for increased glucose, anion gap and beta hydroxybutyrate.  Ultimately, it was believed patient was in euglycemic DKA secondary to SGL 2 inhibitor use and he was admitted to the hospital for further management.   Euglycemic DKA Believed to be in the setting of SGLT2 inhibitor use.  With initiation of insulin and IV fluids patient's gap closed and beta hydroxybutyrate returned to normal.  Patient was maintained in the hospital to initiate insulin in order to optimize home insulin regimen. His insulin requirement for mealtime was increased due to initiation of steroids and treatment of Covid pneumonia.  At the time of discharge she was well managed on 35 units Lantus nightly and lispro 23 units 3 times daily.  He will need continued titration of insulin in the outpatient setting as he has completed his dexamethasone course.  Anticipate lessening mealtime coverage required.   COVID pneumonia & OSA Patient did have weakness and shortness of breath with a new oxygen requirement on the hospital. Initial respiratory viral panel, chest x-ray and CT scan showed no evidence of Covid pneumonia. CT scan did show signs of asbestos exposure. Patient was in the process of being placed secondary to amatory dysfunction and had asymptomatic Covid swab performed which was positive.  Repeat CT scan showed that patient was now showing signs of Covid pneumonia.  With his hypoxia and new oxygen requirement he met criteria to receive inpatient treatment for Covid pneumonia.  He was initiated on dexamethasone x10 days, remdesivir x5 and received convalescent plasma x1.  He was discharged after receiving the full course of all these agents on 2 L NC.  The 10-day quarantine timeframe from time of positive test is 9/13-9/23. Throughout his hospital stay he did receive CPAP at nighttime as he has OSA.  This is an aerosolizing procedure which the facilities were not comfortable with during his Covid positive timeframe.  Options were to send him with oxygen alone versus await 10-day mark when he could go with CPAP.  To ensure this was a safe discharge with oxygen alone to get him to rehab sooner a nocturnal oximetry was performed which showed overnight on oxygen alone nocturnal oximetry shows patient spent 98% of the night above 90% SpO2 on 3 L NC.  He was found to be appropriate for discharge to rehab with transition back to CPAP on 9/24.   Asymptomatic bradycardia Patient was on metoprolol tartrate 50 mg once daily upon admission.  He had a profound bradycardia to the 40-50s.  His metoprolol was reduced to 25 mg and subsequently was held altogether.  This did not alter his heart rate and it remained in the 40s to 50s.  An EKG was performed which did show a profound first-degree AV block with PR interval of 280.  No history of Lyme disease but has had tick exposure.  This was not further investigated as patient was asymptomatic throughout.    Brachytherapy & side effects Patient noticed he had started being incontinent of stool during his admission status post brachytherapy placement on 9/7.  This is likely proctitis related to radiation which can be ongoing.  We recommended he reach out to his radiation oncologist for further information regarding the time course of this.  He has mild abdominal pain which is improving daily.   Ambulatory dysfunction Patient was noted to have falls at home prior to admission.  This was believed to be in the setting of above illness but patient was unsafe to return home where he lives by himself.  Social work was able to find placement at encompass.      a 73 y.o. male presenting with generalized weakness and shortness of breath.  Admitted from the ED with lab findings consistent with diabetic ketoacidosis, which has improved with fluids, as well as new oxygen requirement of uncertain etiology.     Plans   Principal Problem:   Shortness of breath   #. Metabolic acidosis likely secondary to ketoacidosis #. Type 2 diabetes Possibly related to diabetic ketoacidosis given that patient has elevated beta hydroxybutyrate and UA positive for ketones as well as blood sugar of 286.  This may also be contributing to his generalized weakness. ?Repeat BMP pending.  Repeat VBG within normal limits. ?Blood glucose checks every 2 hours ?Start low-dose sliding scale as patient is not on insulin at home. ?IV fluids: Normal saline 100 mL/h    #. Hypoxia with new O2 requirement Patient states that he has been short of breath for the last 2 days. CT the of the lungs did show evidence of exposure to asbestos, but this would be unlikely to cause acute hypoxia.  Given chest x-ray and CT findings, low suspicion for pneumonia.  Though it sounds as if patient may be wheezing when listening to him breathe without the stethoscope, on auscultation lungs are clear bilaterally with no wheezing patient has not received any breathing treatments since arriving at the hospital.  ?Continue supplemental O2 as needed, wean as tolerated ?Continuous pulse ox ?Albuterol nebulizer or DuoNeb every 2 hours as needed per respiratory therapy protocol.   #.  Prostate cancer #.  S/p brachytherapy seed placement 9/7 Some concern for possible side effects due to onset of symptoms shortly following brachytherapy seed placement. ?Consult to radiation oncology.   #.  Urinary frequency UA was positive for nitrites, blood, glucose, and ketones. ?Urine culture pending.   #.  Hyperlipidemia ?Continue home colesevelam 625 mg daily ?Continue ezetimibe 10 mg daily   #.  Hypertension ?Continue home losartan 100 mg nightly ?Continue home metoprolol tartrate 50 mg daily ?Continue home felodipine 10 mg daily   #.  Chronic back pain ?Continue home gabapentin 300 mg twice daily ?Continue home duloxetine 30 mg daily   #.  Gout ?Continue home allopurinol 100 mg daily   Diet: Consistent carb DVT Prophylaxis: Lovenox Disposition: Pending clinical improvement CODE STATUS (LOI): Prior   Patient was discussed who is in agreement with the plan.      Subjective  Chief Complaint   Shortness of Breath and Fatigue     History of Present Illness   a 73 y.o. male with PMH of prostate cancer status post placement of brachytherapy seeds 2 days ago, type 2 diabetes, hypercholesterolemia, HTN, OSA on CPAP, GERD, history of kidney stone who presents with 1 day of generalized weakness and 2 days of shortness of breath..   Patient states that he presented to the hospital because he was getting out of bed at noon yesterday and when he went to stand up he collapsed because he felt that his legs could not support him.  He tried to get back up and was unable to do so.  He crawled to the bathroom.  He said that when he fell he did hit the back of his head, but he did not lose consciousness and remembers the entire event.  He does have a bit of a headache still, but says he has not had any confusion or vision changes since the fall.  His primary complaint is this generalized weakness.   During encounter, patient is on 2 L nasal cannula and clearly short of breath with increased work of breathing.  When asked about his shortness of breath, he says that it started 2 days ago since his procedure for brachytherapy seed placement.  He denies fevers, chills, increased cough, chest pain, palpitations.  Further denies lightheadedness, dizziness.  Says that when he stands up he falls backwards, but that this is related to weakness in his body rather than a feeling like he is going to pass out.   Since his brachytherapy procedure, he has been having urinary frequency which he says was not an issue for him so much before.  States that he needs to urinate every hour.  He was initially having dysuria, but was given a medication for this (most likely Pyridium) which turned his urine orange but caused the dysuria to resolve.  He is unable to see if there is blood in his urine due to urine coloration.  Denies issues with incomplete voiding.   Patient denies smoking, alcohol, illicit drug use.  Ambulates without any assistive devices at home.  Has never needed supplemental oxygen before.  He currently lives alone and is retired, but formerly worked as a plumber.  His primary contact and POA if he were to become unable to make decisions as his brother.   ED Course: Patient brought in by EMS.  Per ED report, patient had a temperature of 100.6 per EMS, but was afebrile on arrival in the ED.  Also on arrival had heart rate 103, respirations 20, blood pressure 162/83, satting 93% on 2 L nasal cannula.  Per ED report, he was satting in the high 80s on room air prior to this.  Since initial arrival heart rate has been in the 80s to 90s.  CBC showed no leukocytosis and normal hemoglobin.  BMP significant for blood glucose of 282, sodium 131 corrected to 134, potassium 3.9, chloride 96, bicarb 19, anion gap 16.  Lactate 1.2.  UA positive for nitrites, moderate blood, glucose, and ketones.  Blood culture and urine culture pending.  I-STAT showed pH 7.39, PCO2 34.  Troponin 0.03.  EKG negative for ischemia but suggestive of first-degree heart block with prolonged PR interval and some regularity in heart rate with possible PAC noted.  D-dimer 5.91, but CT scan negative for PE.  CXR showed no acute cardiopulmonary process.  In the ED patient has received 1 L bolus of NS, but no other medications thus far.  Family medicine consulted for admission of patient with new O2 requirement and generalized weakness.