Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Procalcitonin increased, Pulmonary mass, Renal impairment, Respiratory failure, SARS-CoV-2 test positive
Clinical narrative: 65 y.o. female with a history of CHF, malignant melanoma of torso, CKD, stage 4 chronic renal failure, COPD, atrial fibrillation, hypertension, pleural effusion, and DVT on baby aspirin who presents to the emergency department with her son for evaluation of dizziness. The patient states that last night she was lying in bed when she had sudden onset of light-headedness and dizziness. The patient reports the dizziness feels "like she stood up from the couch too fast". The dizziness does not worsen with movement of her head. The patient denies any pain associated with the dizziness. The patient does note that she fell in her bedroom but is unsure if she hit her head or not. Here in ED triage, the patient did have an episode of urinary and bowel incontinence which she states she has never had previously. The patient is no longer dizzy here in the ED.  DISCHARGE HOSPITAL COURSE: Briefly, this is a 65 yo w/ PMH significant for COPD with chronic hypoxic respiratory failure on nocturnal oxygen, malignant melanoma with metastatic disease in remission but lost follow-up as of recent, pulmonary HTN, chronic diastolic HF, immune therapy induced hypophysitis, DVT, PAF, coming in with concerns of gradually worsening URI symptoms.  Found to be with increasing hypoxia and COVID-positive. For more detail, including PMH, PSH, PFH, Social Hx and further info please see admission H&P.  Hospital course dictated by problem:   Suspect chronic > acute hypoxic respiratory failure Suspect COVID PNA Suspect COPD w/o definitive findings of exacerbation Suspect possible superimposed bacterial PNA Known COPD prescribed oxygen, per review of pulmonology note September 2021 appears to need consistently.  Rate b/w 1-3 L's.  Fully vaccinated aside from booster.  Came in with URI symptoms and shortness of breath.  Was noted to be hypoxic but O2 needs here not from what she has been using at home and consistent with priors from a few months ago.  D-dimer is elevated but CT PE negative for VTE.  Procalcitonin was mildly elevated as well and so started on cefuroxime with doxycycline.  Admitted and started on steroids, anticoagulation.  Had improvement in acute phase reactants, stability/improvement in oxygen needs, symptomatic improvement, and wanting to go home.  Discharged with updated prescription on oxygen, outpatient steroids, doxycycline to complete CAP course, continuation of PTA inhalers.  Seen by her therapy team before discharge she felt safe to go home, discussion with patient she has support from her family members who are also ill with COVID although not as severe. Counseled extensively at length on strict return precautions including worsening respiratory symptoms and increasing oxygen needs at home.   Multiple new pulmonary nodules concerning for metastatic disease History of malignant metastatic melanoma Has followed with primary oncologist April 2021, missed late summer appointment 2021 as she was in another location for few months.  CT imaging as described concerning for possible malignancy.  Counseled at length the importance of calling her primary oncologist Dr. for follow up as soon as possible for ongoing follow up and assistance with these new findings, once she recovers from her acute illness would likely benefit from biopsy.   Immune therapy induced hypophysitis Suspect secondary hypothyroidism from above Known hypophysitis which patient does not recall.  Inadvertently taken off prednisone during pulmonology follow-up September 2021. A.m. cortisol 4, ACTH <5.  Electrolytes and blood pressures are stable.  When she completes the higher dose Decadron prescribed Decadron 2 mg to take as a bridge until she has outpatient follow-up with her primary care will need to further spearhead this.  Also provided an endocrinology referral as she would be best served by their cares from this issue.  Reassured that TSH and T4 here are adequate, continue PTA Synthroid.   Elevated troponin but age appropriate Abnormal EKG Concern for inferolateral ST changes, but serial troponins WNL and echo w/o focal WMA. Advised on PCP f/u for consideration of outpatient ischemic workup such as stress testing.   PAF not previously anticoagulated Longstanding and well-documented history of PAF.  Did not come in anticoagulated.  With her CHA2DS2-VASc score <2 and after discussion with previous provider started on Eliquis here which she will continue until it is felt to be contraindicated.  Please note her renal function appears to fluctuate and this will need to be closely monitored with consideration of dose adjusting outpatient to a lower dose.   T2DM w/ suspected steroid-induced hyperglycemia Last A1c 7.7 2 months ago.  Previously on metformin but stopped taking for reasons unclear.  Hyperglycemic here fitting with known diagnosis of DM, likely exacerbated by steroids.  Was managed with SSI here.  Given fluctuating renal function did not feel safe to start metformin, started on low-dose glipizide advised on close outpatient follow-up instead.  Rate advised on hypoglycemia management and hyperglycemia management as well.   Chronic HFpEF Chronic HLD W/o findings of hypervolemia/acute exacerbation. Lasix was held on admission, noted to have improving renal function. Advised to hold Lasix given elevated Cr on admission and to work w/ PCP on when to safely restart. Should continue PTA ASA and Lipitor, however.   CKD unclear stage Baseline Cr ~1.5-1.6. Down-trended w/ holding of Lasix.  With prior history of baseline CR being higher, likely need to introduce Lasix later this dictated discharge medication management as addressed above.  This should be closely followed and managed by outpatient primary care, consideration for nephrology referral depending on where her renal function sits.