Age: 53.0
Sex: M
Vaccine: COVID19-2
Symptoms: Hypophagia, Hypovolaemia, Hypoxia, Lactic acidosis, Malnutrition
Clinical narrative: Patient is a 53 y.o. male who presented from home on 3/7/2023 with dyspnea. Patient found to have COVID 19 infection.  Patient was also noted to have lactic acidosis.  He also did have pain that was difficult to control during hospitalization.  He was seen with ancillary pain team and he did not titrate some of his medication he did have a little bit of improvement in his pain.  His lactic acidosis did improve with hydration and his breathing did improve he was discharged in stable condition.   Dyspnea  Fatigue Generalized weakness - etiology may be related to covid 19 infection; may be volume related as well with hypoalbuminemia related to poor nutritional status less likely CHF exacerbation  - pt reports one day of dyspnea that is worse on exertion - denies orthopnea, PND, CXR on admission unremarkable, BNP only mildly elevated  - pt reported to have oxygen saturations 78% at home and required 4 L NC per EMS: Presented with oxygen saturations in the 90s, transitioned to 2 L overnight for believed hypoxia -Patient was able to wean down to room air and had no difficulty breathing the day of discharge.   Lactic acidosis - etiology may be due to poor oral and nutritional intake; intravascular depletion in context of current covid infection; despite peripheral edema.  No concern for endorgan ischemic state. -Presenting lactate 4.3, downtrend to 3.8, recheck 4.7, and WBC 7.19 -Blood cultures 3/8 no growth to date - BP stable, pt denies abdominal pain; no evidence sepsis, hold off on antibiotic administration - noted prior hx of euglycemic DKA though no evidence here as pH and bicarbonate wnl  -Lactate did improve and was within normal range at the time of discharge.   DM2 with hyperglycemia and polyneuropathy -A1C 8.3  on 12/28/22. Home regimen: Ozempic every Sunday, Tresiba 10 units, no prandial insulin -With episode of false hypoglycemia.  His blood sugar was as low as 16 on finger prick, when taken from his earlobe he was found to be 134.  He is fingers were cold on exam so I suspect there was a component of this.  He is suspicious that he had not been having problem with this previously, he does not appear to have Raynaud's on exam. -Patient did have hypoglycemic episode on 3/9 in the PM that was symptomatic -He was continued on his home insulin regimen on discharge.   Acute on chronic low back pain -Acute worsening of pain per pt for last 2-3 weeks; pt reports most recent fall in end of 12/2022; with chronic leg pain; no new radiculopathy  -CT T/L spine non acute -He states that his pain is better controlled. -Ancillary pain team consulted.  They are continuing his current medications and they are starting lidocaine patch and Norflex 60 mg IV every 12 hours.  They have increased the frequency of Percocet to every 6 hours.  Also continue gabapentin 600 3 times daily  -He was continued on his home pain regimen.  Did add tizanidine 4 mg twice daily at his request as a muscle relaxant had helped him.   Covid 19  - Presented with: fatigue, dyspnea, poor oral intake though symptoms chronic and unclear if related to covid 19 or no - Symptom onset: above symptoms started around 3/3 though not clearly covid related; therefore unknown  - Positive COVID-19: 3/7/23 - CXR on admission unremarkable  - Oxygen status: 90%'s on RA   - Decadron: Does not qualify due to SpO2>94% on RA.  - Remdesivir: Does not qualify due to SpO2>94% on RA. - DVT prophylaxis:Currently on full anticoagulation - Serial COVID labs ordered: No - Case Management/Social Services consulted: Yes  -E consult placed to infectious disease for consideration of Paxlovid, however contraindicated because of several medication interactions   Bilateral LE edema -multifactorial and likely from hypoalbuminemia (albumin low at 1.9 last hospitalization) from poor nutritional state post bariatric surgery  - leg edema out of proportion to CHF as noted in prior cardiology notes (1/25/23)- - last TTE on 12/2022 did not show right heart failure or diastolic dysfxn and EF was normal, urine Pr:Cr ratio was not elevated, CT did not show cirrhosis. Lower ext duplex 1/19 showed no DVT and pt already on eliquis  -Albumin 2.1, chronic per medical record -Diuretics were held inpatient. -He did have an appointment with Dr. that he was not able to attend.  We will need to call him to reschedule this. -Resumed him on his home Lasix on discharge.     Chronic HF with recovered EF -Hx of NICM with EF 35% in 2011, had normal LHC at that time and EF recovered. Dobutamine stress echo Feb 2022 was unremarkable.  -TTE 12/29/22 showed EF normal 55%, RV size and sys fxn normal, no diastolic dysfxn, could not estimate RVSP.  -BNP mildly elevated at 457  -pt with poor oral intake; with noted peripheral edema; though not clearly CHF exacerbation - elevated lactic acid; low suspicion cardiogenic shock - holding lasix for now; pt had been on ARB and beta blocker in past and has been discontinued in past due to orthostatic hypotension  - cardiology consulted, patient is very well known to service, based on clinical picture team canceled consult, did not believe symptoms were cardiac related   Recent PE -Diagnosed 12/10/22- bilateral segmental branch without heart strain, possibly provoked with preceding travel. Was also referred to hematology -Continue home Eliquis 5 BID.     Chronic normocytic anemia -Recent B12/folate normal 12/29/22, iron studies with ferritin 12/13/22 do not show iron deficiency.  -Hb stable at baseline .   BPH -Flomax recently stopped due to orthostasis and has not had issues with retention  -monitor    History of RNYGB -about 3-4 years ago -Follow up outpatient with bariatrics.    OSA -Patient unable to tolerate facility CPAP, transitioned to 2 L nasal cannula at at bedtime -Patient advised to have family bring in his home CPAP