Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Haematuria, Haemoglobin decreased, Headache, Hepatic cirrhosis, Hydronephrosis
Clinical narrative: 12/7/2021 - present (3 days) inpatient admission  HISTORY OF PRESENT ILLNESS: a 65 y.o. female with a PMH of  venous insufficiency , chronic kidney disease, psoriasis on Humira, OSA with nightly BiPAP dependence, mild MR, mild AS, hypertension, anxiety and chronic anemia who presents today with weakness, fatigue, cough, anorexia, headaches and dizziness.  The patient has known exposures to people with COVID-19.  She received both Pfizer vaccines, last 07/14/2021.  She has not had a chance to get her booster shot as of yet.  She states that prior to Thanksgiving her sister was hospitalized with COVID-19 and she had been in contact with her.  She states that on Thanksgiving she stayed home because she did not feel well.  She has had sweats, chills, generalized malaise, altered taste and smell in addition to the above initial complaints.  She denies any chest pain.  She has noticed increased swelling in her lower extremities.  She did not take any of her home medications prior to arriving today.   In the ER, the patient was tachycardic with a pulse of 106, mildly febrile with a temperature of 37.9° C. Tachypnea with a respiratory rate of 33.  The patient was not hypoxic on ambient air.  Labs significant for BUN 23, creatinine 1.28, albumin 2.3, lipase 88, NT proBNP 2855, WBC 12.33, hemoglobin 7.2.  COVID-19 PCR was positive.  CXR with mild cardiomegaly with pulmonary vascular congestion.  FOBT obtained in the ER was heme positive. The patient received 1 g of Tylenol, 1 L of IV fluids and 20 mg of IV Lasix.     The patient will be admitted for further evaluation and treatment. ASSESSMENT / PLAN: Acute on chronic blood loss anemia Gross hematuria -Suspect urinary source given patient report of gross hematuria  - history of recent right lithotripsy on 10/21.  Has a history of post lithotripsy hematoma during a past lithotripsy. -Trend hemoglobin Q 8 hours, transfuse for Hgb <7.  Pt signed blood consent in ER.  Given to ER secretary.  The consent will be tubed to the floor for scanning once she arrives. -Consult Urology.  Have asked RN to straight cath for urinalysis as patient is incontinent.   -FOBT was positive in ER, however tarry or red stool not noted.  Patient reports no rectal bleeding or tarry stool.  She does take iron so her stool is dark.  EGD/Colonoscopy 7/2019 with normal EGD exam.  No bleeding lesions or cause for anemia.  Colonoscopy with moderate pandiverticulosis moderate. 15 mm sessile polyp, located in the cecum, which was completely removed but specimen was unable to be retrieved.  Small polyps could have been missed. -Hold ASA for now   Acute on chronic congestive heart failure with preserved ejection fraction New onset Atrial Fibrillation -NT-pro BNP up 1116 (July/2021) -- > 2855 upon arrival -CXR with mild cardiomegaly with pulmonary vascular congestion -Lower extremity edema noted on exam -Given 20 mg of IV lasix in ER (had received 1 L of IVF) -Continue home dose oral lasix going forward  - monitor daily weights, I/O, 2 G NA restriction, 2 L fluid resriction -EKG with A-fib (no previous episodes on EKGs), monitor on telemetry,  check TSH. With chronic anemia and intermittent bleeding - likely would be a poor candidate for OAC -ECHO 7/23/21: LVEF 58%, mild AS, mild MR, diastolic function indeterminate.   COVID-19 infection -Vaccinated x 2 - had not had a chance to get booster.  On Humira. -Symptom onset 11/26 or earlier.  Not a candidate for MAB. -Symptoms: Generalized weakness, cough, rhinorrhea, anorexia, dizziness, headaches, sweats and chills, altered taste and smell -CXR without signs of COVID-19 -If patient develops further symptoms such as hypoxia  - Decadron can be started.  She is out of the therapeutic window for Remdesivir. -Unable to offer VTE prophylaxis with Lovenox given possible active bleeding.  SCDs are ordered. -Supportive care with anti-tussives, PRN Tylenol for any fevers   Hypertension -Continue metoprolol and norvasc within parameters.   OSA with nightly Bi-pap dependence -OSA power plan ordered -Continuous pulse oximetry   Psoriasis -Receives Humira every 14 days   FULL CODE  Diet: Heart Healthy, 2 L fluid restriction, 2 G NA VTE Prevention: This patient is high risk per the VTE risk assessment tool, however pharmacologic prophylaxis is contraindicated due to bleeding. SCDs have been ordered.