Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Abdominal pain upper, Acute kidney injury, Anaemia, Anion gap normal, Back pain
Clinical narrative: Date of Service Nov-10-2021 1353  Chief Complaint Black Stools  HPI / Subjective Patient is a 68 yo man who presented to an outside facility for shortness of breath in the setting of COVID-19 and was found to have acute anemia. He was transfused one unit PRBCs and transferred to Hospital under the care of the website. He was diagnosed at the outside facility with positive COVID pneumonia, anemia, acute kidney injury with dehydration. Past medical history is significant for gout, essential hypertension, allergic rhinitis, back pain, OSA on CPAP at night, and hyperlipidemia. Today is hospital day 1 including time at the outside facility.   Today visit the patient will is resting comfortably in his bed after being delivered by the EMS service.  He is in no acute distress and converses with me pleasantly.  His English is somewhat broken but clear, easy to understand and generally complete.  I can tell when he struggles to understand me and work to ensure understanding. Patient reports feeling strange over the last few weeks. It started a little before the 2nd of Novemeber. He went to his pcp with complaint of some sneezing, throat symptoms, and cough. He was screened for covid (rapid was negative, PCR was positive) on 11/2/21. He has been vaccinated with the Pfizer/BioNTech vaccine back in March during a group vaccination event. At his pcp he refused ivermectin and REGEN-COV.  He continued to feel ill and presented to the ED at County hospital on the night of 11/9/21. Patient was watched overnight with worsening oxygen requirements. Patient was admitted to their hospital after his hemoglobin dropped from 8 to 7.7 to 6.4 in the span of about 1.5 days. Troponins at outside facility were trended initial test 0.04, subsequent 0.05, final test 0.04.  Lactic acid was 1.5 on 11/8/2021 at 11:03 p.m.  Send out labs from County include: Folate 6.9, normal  Ferritin 402, high  Vitamin B12 551, normal Arterial blood gas done at outside facility:  PH 7.38,  pCO2 29.8,  PO2 32,  HC03 18,  base excess -7.0,  TCO2 19.0,  O2 sat 61   At our facility,  Patient is mildly symptomatic. He reports some epigastric pain. He reports his stools are dark. He is not seeing stars or feeling sleepy. He does not have a feeling of fainting when standing. He is requiring 2-3 L oxygen to maintain saturations above 91%.   Patient wears CPAP at home for his OSA.  He is a nonsmoker but drinks tequilla weekly.  Allergies No Known Allergies  Social History marital status Married  Primary Care Provider Doctor  REVIEW OF SYSTEMS CONSTITUTIONAL: Patient denies unexplained weight loss, fevers, and chills EYES: Patient denies vision changes and eye pain EARS, NOSE, & THROAT: Patient denies sore throat and ear pain CARDIOVASCULAR: Patient denies chest pain and palpitations RESPIRATORY: Patient endorses dyspnea and cough GASTROINTESTINAL: Patient denies abdominal pain, nausea, vomiting, diarrhea, and constipation GENITOURINARY: Patient denies dysuria and hematuria MUSCULOSKELETAL: Patient denies specific myalgias and arthralgias INTEGUMENTARY/BREAST: Patient denies wounds and rashes NEUROLOGICAL: Patient denies confusion and headache, lightheadedness PSYCHIATRIC: Patient denies depression and anxiety HEMATOLOGIC/LYMPHATIC: Patient denies excessive bleeding and easy bruising  Vital Signs Nov-10-2021 1327 T 98.4 HR     114 RR 18 BP   149 / 71 O2Sat 96 PHYSICAL EXAM CONSTITUTIONAL: Patient appears stated age and in no acute distress. EYES: Vision is grossly intact, pupils are equal, and conjunctivae are  mildly injected and  without pallor. EARS, NOSE, & THROAT: Oral mucosa is moist and the tongue is without fissures. No thyromegaly or cervical lymphadenopathy noted. CARDIOVASCULAR: Regular rate and rhythm without murmurs, gallops, or rubs. Pulses are 2/2 in the bilateral upper and lower extremities. No edema noted. RESPIRATORY: Lungs are clear to auscultation bilaterally without rales and wheezes. Respiratory effort is not labored. No retractions or accessory muscle use noted. GASTROINTESTINAL: Abdomen is soft,  mildly tender, and nondistended. Bowel sounds are normoactive.  MUSCULOSKELETAL: Strength 5/5 in the bilateral upper and lower extremities. No skeletal deformities noted. SKIN/BREAST: Skin is warm, dry, and without wounds, rashes, and concerning lesions. NEUROLOGICAL: Patient is alert and oriented to person, place, time, and event. Sensation is grossly intact in the head and bilateral upper and lower extremities. PSYCHIATRIC: The patient's mood is euthymic and affect is appropriate. RASS of 0. HEMATOLOGIC/LYMPHATIC: No bruising or active bleeding noted. no petechia present  Lab Results Nov-10-2021 1510 Chemistry GLUCOSE  109BUN  72CREAT  2.3MDRD GFR  28NA  147K  4.7CL  115CALCIUM  8.0CO2  19.2OSMO  314.2ANION GP  17.5BUN/CRE  31.3LDH  229TRIG  185CHOL  129LDL CALC  70HDL CHOL  22REL RISK  5.9LDL/HDLD  3.18CRP  17.20 Nov-10-2021 1510 Coagulation PT  10.8INR  1.0D-DIMER  2.54 Nov-10-2021 1510 Hematology WBC  7.5RBC  2.52HGB  7.3HCT  22.0MCV  87.3MCH  29.0MCHC  33.2RDW  15.4RDWSD  49.1PLT  465MPV  8.7AUTONEU%  81.4AUTOLYM%  5.6AUTOMON%  5.4AUTOEOS%  1.1AUTOBAS%  0.1AUTONEU#  6.1AUTOLYM#  0.4AUTOMON#  0.4AUTOBAS#  0.0AUTOEOS#  0.1NRBC%  0.0NRBC  0.0IG#  0.48IG%  6.4 Nov-10-2021 1510 Serology PROCALC  0.30 Imaging Results chest x-ray from 11/9/2021 at outside facility: Briefly reviewed, no obvious pulmonary process  Plan ASSESSMENTS:  Acute blood loss anemia, possibly secondary to GI losses  Possible GI bleed with occult blood done at outside facility positive Acute renal insufficiency, present on admission BUN 110 and creatinine 2.5  from outside facility  Leukocytosis Elevated platelets  Elevated D-dimer Recent transfusion of packed red blood cells Lumbago Sleep apnea treated with CPAP Essential hypertension  Gout  PLANS:  admit to the PCU under the care of Internal Medicine for a minimum of 2 midnight stay and estimated length of stay of 2-5 days.  The patient warrants admission due to unstable blood loss of uncertain severity  After transfer patient was  stabilized and blood was drawn for labs.  We are watching his hemoglobin closely.  It is probable that patient has a GI bleed and we have started the patient on Protonix 40 mg orally b.i.d..   Due to platelet derangement a prothrombin time was ordered.  we will continue to biochemically watch this patient and intravene   as necessary.  -CODE STATUS:  Full code  The patient was evaluated by  Doctor and the plan of care was discussed with this [resident]. Doctor  Justification for Hospitalization Please document severity of illness/comorbidities and intensity/duration of the treatment to justify hospitalization (Probable brisk GI bleed.)  CODE STATUS Full Code  HEALTHCARE PROXY/AGENT Name: [ ] Relationship: [ ] Contact Info: [ ]  Advanced Care Planning Discussion Date: [ ]  Individuals Present: [ ]  ORGAN or TISSUE DONATION [ ]  RELIGIOUS/CULTURE CUSTOMS OR PREFERENCES [ ]  FORMS ON FILE [Living Will/Durable power of attorney for health care/POLST/MOLST/Other advance care planning documents]  TIME SPENT [ ] Minutes  Electronically signed by Doctor on Nov-10-2021 1607 I have seen and examined the patient and agree with the history and physical as documented by Doctor. Please refer to the resident's history for complete details. Below is a summary of my additional findings done after my first encounter with the patient. I have discussed the plan of care with the resident. At the time of my evaluation the patient denied black/tarry stools or blood in his stools. He states that he has not noticed any bleeding from his nose, no blood in his urine, no obvious cuts or scrapes, and denies vomiting blood. He has not had a history of GI bleed or peptic ulcer disease. Patient seems hemodynamically stable this point time. He has had a 2 g drop in his hemoglobin over the last 24 hours. He presented initially with anemia which makes me concerned there may be an underlying process causing his anemia. Patient does need endoscopy, both upper and lower, the near future however I do not think at this time there is a need for urgent endoscopy especially given his COVID-19 positive status as this would increase the risk for nursing staff and physicians given the aerosolization COVID-19. Will consider outpatient endoscopy for workup of his anemia at the time of discharge. Electronically signed by Doctor on Nov-10-2021 1622