Age: 71.0
Sex: M
Vaccine: COVID19-2
Symptoms: Lung infiltration, Mycoplasma test, Myocardial ischaemia, Orthostatic hypotension, Pancytopenia
Clinical narrative: The patient is a 72 y.o. male patient of a DO with history of hypertension, hyperlipidemia ,  CAD, CKD IIIb and recently diagnosed rare bone marrow cancer (proliferative  glomerulonephritis with monoclonal IgG deposits PGNMID after bone marrow biopsy  on 3/22/2022 at hospital and has been on chemo with doctor) presented to Hospital with generalized weakness, chills and falls at home. He was found positive for COVID 19 infection on 4/4/23 with home kit.      Near syncope Orthostatic hypotension Dehydration  Falls at home Likely due to dehydration/poor intake  from COVID 19 infection Orthostatic vital signs positive from 4/13/2023.  Repeat orthostatic vital signs today- improved  PT/OT consulted.  No skilled needs identified. Patient on Kerendia 10 mg daily at home.  Discussed with patient's outpatient nephrologist doctor.  Holding it for now.  Can be restarted once no longer orthostatic vital signs positive. Decreased Coreg to 3.125 mg BID. IVF given Improved  Ambulatory without difficulty.   Covid-19 Virus Infection COVID Pneumonia Date of onset of symptoms: 4/1/23 Symptoms present on admission: weakness,chills, abdominal cramps Date of covid positive test: 4/423 with home kit.  COVID test positive in ER on 4/12/2023 Vaccination status: vaccinated Imaging: CXR from 4/10 negative, repeat CXR -mild interval worsening of multifocal hazy infiltrate Oxygen requirements on admission: RA Current oxygen requirements: RA Medical therapy: not indicated and not a candidate ID consult Anticipated special isolation end date: tbd Patient had wheezing on exam and was started on prednisone 40 mg daily x5 days AST/ALT 94/93 on 4/16 and monitor   Sepsis Pancytopenia Developed fever as 103 not responding to Tylenol since admission.  Likely etiology is COVID infection On chemotherapy with Daratumumab plus VCD including velcade, Cytoxan and dexamethasone.  Last dose 2 weeks ago per patient.?  3/7/2023.   No neutropenia.  ANC 2640.  PCT elevated at 1.26.  CRP 36.8.  LA normal Blood culture x2-no growth to date.  Fungal culture-no growth to date. UA unremarkable. EBV IgG positive. HSV PCR neg Mycoplasma IgM pending Fungitell pending, Histoplasma urine Ag pending Urine Pneumococcal Ag and Legionella Ag neg Chest x-ray from 4/13/2023-multifocal hazy infiltrate-consistent with known COVID viral pneumonia. ID following Started on Levaquin, vancomycin and cefepime and levaquin stopped CT C/A/P 4/4 showed COVID pneumonia Discussed with ID.  No fever in past 48 hours.  Work-up has been negative so far, likely fever.  COVID okay to stop antibiotics.  Okay for discharge.   Incidental Findings on CT Left thyroid nodule Right lower lobe nodule, granuloma Infrarenal Abdominal Aortic aneurysm, up 2.7 cm Plan for outpatient follow up with PCP and Dr Thyroid u/s CT chest in 3 months AAA follow up with PCP   AKI on CKD IIIb, improved Likely due to pre-renal azotemia Baseline creatinine 1.5-1.7, admit creatinine 2.2> 1.95> 1.57 Gentle hydration Avoid nephrotoxic agents Follows with Dr Cr 1.1 on 4/16   Elevated transaminases Mild elevation of transaminases noted since admission.  Likely secondary to COVID.  Initial CT chest abdomen pelvis did not show any abnormalities to the liver or gallbladder.  Can follow-up with PCP.  Discussed with patient and wife     Elevated troponin Likely from demand ischemia and poor creatinine clearance Initial troponin 27> 21.  Not consistent with ACS.  No chest pain Limited 2D echo with EF 65+/- 5%.   Proliferative  glomerulonephritis with monoclonal IgG deposits (PGNMID) Diagnosed after bone marrow biopsy  on 3/22/2022 at other hospital On week 42 of  chemo , did not take for the past 2 wks Follows with doctor, resume on discharge Chronic DVT in an isolated area of mid femoral vein in RLE Complex popliteal cyst Venous Doppler from 4/13/2023--chronic deep vein thrombosis in an isolated area of the mid femoral vein in RLE. Patient has no prior study or aware about DVT Discussed with Dr. Recommended to start AC.  As patient's platelet is low patient carries a higher risk for bleeding.  This was discussed with patient and wants to be on blood thinner.  But his platelet has been running stable for some time. Started on Eliquis 4/13/2023-continue.   PLT stable and no evidence of bleeding Did not perform CTPA to rule out PE due to elevated creatinine and as the management does not change as he is already on Eliquis