Age: 93.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal discomfort, Acute respiratory failure, Agitation, Blood bilirubin increased, Blood creatinine normal
Clinical narrative: This is a 94-year-old female brought in by EMS given family's concern for decreased oral intake over the past several days and apparent lower chest/upper abdominal discomfort, in the setting of progressive dementia with behavioral disturbances, IDDMII (HbA1c 6.6% 5/2017), Hypothyroidism, Osteoporosis and remote history of CABG, found to be afebrile and hemodynamically stable, agitated, disoriented, clinically dehydrated and uncomfortable appearing on exam, labs notable for CBC and electrolytes within normal limits, sOsm elevated 299, BUN 25 and creat 0.9 (baseline ~0.5), Tbili 2.4 and lactate 2.4, COVID positive, CXR with bibasilar infiltrates, admitted to medicine for dehydration and failure to thrive.  Failure to thrive Dehydration Anorexia Hypoalbuminemia / Protein-Calorie malnutrition Clinically dehydrated on exam, with elevated serum osm, BUN/Creat, and borderline AKI, with reported anorexia over the past several days.  Unclear whether this is being driven by acute abdominal symptoms or systemic illness versus progression of underlying dementia and/or inadequate home care. Excepting evident epigastric discomfort, no localizing symptoms on exam/initial studies including abdominal tenderness, evidence of UTI on UA, or bacterial PNA on CXR, however positive for COVID, which raises possibility of systemic inflammation driving these constitutional symptoms. -No significant electrolyte derangements  > Trend elecrtolytes including Phos/Mg -Received IVF in the ED  > Follow up AM lactate  > ongoing maintenance IVF, NS at 100ml/hr -Add CRP, LDH, fibrinogen *Appreciate CM, PT, and Nutrition involvement  Epigastric discomfort noted by family to be clutching her lower chest/upper abdomen. This together with recent anorexia most concerning for intra-abdominal process including gastritis, gastroenteritis, less likely pancreatitis or ACS. Absence of abdominal tenderness, fever, hemodynamic changes, and leukocytosis point away from acute biliary pathology, appendicitis, perforated viscus. -Add lipase -EKG -Trend Bilirubin -Trial famotidine BID  Borderline AKI BUN elevated and Creat elevated from baseline. Most consistent with prerenal AKI. UA without evidence of UTI, reported casts. No recent nephrotoxins. No history to suggest obstruction. s/p IVF -Trent BUN/Creat -Strict I/Os, monitor volume status:  Goal for euvolemia > Bladder scan if UOP down > Further workup with Urine micro and Urine lytes if worsening  COVID-19 disease Acute hypoxic respiratory failure COVID-19 disease, due to SARS-CoV-2 infection +SARS-Cov-2 PCR 11/25 Symptom onset: several days prior to admission, anorexia, epigastric pain (?) Identifiable exposures: None Initial labs notable for: Normal CBC, CMP with Tbili 2.4, elevated CRP, fibrinogen, LDH Initial chest imaging with bibasilar opacities. On presentation, neither hypoxic nor tachypneic (however pulse ox on ear). On arrival in the RCU, sats 80s on room air, up to mid 90s on 5L. Low clinical suspicion for PE in the absence of symptoms or signs of DVT on exam, pleuritic chest pain, hemoptysis, likewise absence of chest pain, anginal equivalents or acute ischemic changes points away from ACS.   Deferring further workup with D-dimer and troponin at this point. -Admit to RCU: contact/airborne precautions -Supplementary Oxygen: Titrate O2 92-96% -Dexamethasone 6mg daily x 10 days or until discharge -Remdesivir 200mg x 1, 100mg every 24h x 4 doses > monitor renal function and liver chemistries -Strict I/Os, monitor volume status:  Goal for euvolemia -Encourage incentive spirometer use and proning -APAP PRN for pain/fever -Albuterol PRN for wheezing -Benzonatate PRN for cough > Discharge planning Ambulatory O2 challenge daily (once O2 req stable < 4L)