Age: 89.0
Sex: F
Vaccine: COVID19, FLUA4
Symptoms: Enterococcus test positive, Escherichia test positive, Gastrointestinal haemorrhage, Glomerular filtration rate decreased, Haematochezia
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD Admission Date: 9/30/2022 Discharge Date: 10/12/2022  PRESENTING PROBLEM: Intra-abdominal fluid collection Gastrointestinal hemorrhage, unspecified gastrointestinal hemorrhage type   Patient is a 89 yo Female with PMH of hypertension, hyperlipidemia, Afib on Eliquis, Overactive bladder on oxybutinin and debility using a wheelchair to go to office appointments with daughter who presented to the hospital for hematochezia noted by daughter.  Pt lives with daughter who is her primary caregiver.  It was also reported that pt had been having some intermittent abdominal pain.  In the ER, pt found to be hypertensive, WBC 11, hgb 12.3, Creatinine 1.13.  She had CT A/P performed which showed multiple fluid collections (6.3 x 2.3 x 2.9, 2.9 x 2.2 cm, 5.1 x 3.8 cm). General surgery was consulted who recommended non-operative mgt and IR consult for drainage. She was started on IV Zosyn and admitted to Medicine with Eliquis held in prep for procedure.  Surgery recommended she remain NPO.  Also, of note pt found to be COVID-19 positive, but no respiratory symptoms and satting > 90% on RA.  CXR did show streaky b/l airspace disease.    After admission, it was noted she had rectal bleeding felt could be secondary to hemorrhoid though internal colon mass not excluded and Surgery recommended GI consult for C-scope.  GI evaluated and did not recommend immediate scope given concern for diverticulitis causing fluid collections and would set this up in 6-8 weeks post discharge. GI did recommend pt MRCP/MRI given biliary dilatation seen on CT A/P. Infectious disease was consulted given concern for infectious fluid in abdominal and recommend conditioning IV antibiotics to ceftriaxone/metronidazole.  Pt did develop AKI, suspect due to volume depletion/dehydration and IVF increased.  She was noted to have limited UOP, UA with large blood and Urology consulted with Urine cx ordered and medical cytology of urine.  Urine cx ultimately showed no bacteria.  Urine cytology showed no malignancy.     In terms of COVID 19 diagnosis, was felt she would be probably benefit from remdesivir but held off given AKI with low GRF.    Patient had abdominal drain placed by IR on 10/03.  Culture result from fluid collected finalized as enterococcus, streptococcus and e.coli.  ID recommends 3-4 weeks of IV antibiotics with repeat CT imaging at end of therapy.   For patient's urinary retention/hematuria urology was consulted.  Urology recommends cystoscopy in 6-8 weeks.   MRCP came back showing possible hepatic mass. MRI abdomen with contrast was done, which showed multiple liver masses.     Nephrology was consulted and recommended Foley placement for accurate assessment of I/Os.  Kidney function improved and normalized.   She continued to have poor oral intake. Discussed prognosis with patient and family and daughter who is DPOA. Hospice was consulted. Code status was changed to comfort care.  Patient was discharged with hospice care.