Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Blood albumin decreased, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium decreased, Blood chloride normal
Clinical narrative: 71 man with afib previoulsy on pradaxa, HTN, CKD 3, OSA on CPAP, residing in facility since 12/23/21.  Patient initially had elective lumbar laminectomy decompression on 11/12/2021, later complicated by PE, DVT on 11/14/21, had IVC filter placed and started lovenox 11/20 and discharged.  Returned to the hospital 11/24/21 for epidural hematoma, underwent urgent T5-10 and T11-L4 laminectomy on 11/24.  hosp course further complicated by worsening bilateral DVT clot burden requiring mechanical thrombectomy 12/1/21, recurrent epidural hematoma requiring 2nd laminectomy for hematoma evacuation 12/4.  Developed AKI that resolved, neurogenic bowel/bladder required foley.  It was suspected that he may have acquired hypofibrinogenemia required Riastap fibrinogen concentrate vs chronic DIC causing recurrent hematoma.  He was bridged with heparin and started on coumadin, discharged to facility on coumadin 12/23/21.   Patient developed symptoms of cough and fever on 1/4/22. Pt tested +for Covid 1/8/22 and brought to ED 1/9/22 for increased cough and O2 sat 91 on RA and admitted for Covid PNA. Last foley change was about 1 week PTA. In the ED, CTA again showing bilateral PE     1) COVID Pneumonia with Acute hypoxemic Respiratory failure and severe sepsis- Symptom onset on 1/4/22. COVID positive on 1/8/22. Last fever on 1/9/22 Met criteria for severe sepsis on admission with fever, tachycardia, and resp failure and pt was started on Remdesivir (completed 4 doses) and steroids with symptomatic improvement. Pt now weaned down to room air. Pt to complete course of steroids ending on 1/18/22. Cont pepcid while on steroids.    2.  S/p recent lumbar laminectomy 11/12/21 complicated by DVT/PE and recurrent epidural hematomas requiring evacuation 11/24 and 12/4/21. It was suspected that he may have acquired hypofibrinogenemia vs chronic DIC causing recurrent hematoma. Now with bilateral LE weakness, neurogenic bowel and bladder requiring foley.  Recently completed decadron taper 1/2/22. Failed voiding trial 1/3/22 and foley reinserted 1/4/22. Plan: cont bowel regimen cont with foley, flomax Follow up spine surgery 1/27/22 for suture removal PT skilled for SNF    3.  Bilateral DVT, PR - diagnosed 11/13/21 s/p IVC filter 11/14/21 with further worsening clot burden s/p mechanical thrombectomy 12/1/2, also had thrombocytopenia. Bridged with heparin, coumadin goal 2-2.5 given epidural hematoma.  Per heme notes, suspected he has chronic DIC vs acquired hypofibrinogenmia, prior work up without indication of underlying malignancy. He is subtherapeutic on admission and started on IV heparin.  Case discussed with hematology, spine surgery, and pt's hematologist Dr.  from 1/10/22, suspicion that cause of bleeding last time was low fibrinogen level and lovenox started <10 days post op.  All are in agreement for continued heparin until coumadin therapeutic. IV heparin DCed on 1/12/22.  Plan: Next INR check on 1/14/22 and then take as directed by anticoagulation clinic Anticipate 6 months anticoagulation Trend fibrinogen level qWeekly, first check on 1/20/22 Has heme follow up with Dr. 1/22/22   4.  PAF - pt has been in NSR, not on rate/rhythm agents at baseline.    5.  OSA - holding CPAP while on isolation, can provide nocturnal O2    Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Severe Sepsis, Covid PNA