Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Blood phosphorus, Bone marrow failure, C-reactive protein increased, COVID-19, Capillary nail refill test
Clinical narrative: Hospitalized (1.26.22 - 1.31.22); COVID-19 positive (1.26.22); Fully vaccinated -moderna x2 D/c summary:  Physician ? ? Hospitalist BRIEF OVERVIEW: Discharge Provider: doctor of osteopathic medicine Primary Care Provider: family nurse practitioner Admission Date: 1/26/2022 Discharge Date: Jan 31, 2022 Active Hospital Problems   Diagnosis Date Noted POA ? Paroxysmal atrial fibrillation 01/27/2022 Yes ? COVID-19 01/27/2022 Yes ? Pancytopenia 01/27/2022 Yes ? Type 2 diabetes mellitus, with long-term current use of insulin 01/27/2022 Yes ? CAD (coronary artery disease) 04/06/2021 Yes ? HTN (hypertension) 03/25/2019 Yes  Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Acute CHF (congestive heart failure) 01/27/2022 01/31/2022 Yes   Discharge Disposition:  home health care svc  Active Issues Requiring Follow-up:  * Pancytopenia Slightly worse WBC today (1.6 > 1.3), afebrile Stable Hb at 7.3  - Hb 9.7 after 2 units pRBC's transfused. The following day it was 8.1 followed by 7.3, 7.3. - Plt count stable in the 50's for last 4 days - FOB has been ordered and remains pending d/t no BM.   - Per discussion w/ heme-onc suspect covid-mediated, but cannot r/o other etiologies including nutrition deficiency (B12/6/1, Fe, Zn, Cu), hemolysis, or bone marrow failure such as myelodysplastic syndrome. Plan to initially begin with less-invasive testing prior to proceeding w/a Bx. - CBC w/diff & smear - pathologist to review - LDH - B1, B6, B12, Zn, Cu, Fe studies in am - HEME molecular sequence analysis for non-invasive way to eval for MDS, Leukemia/Lymphoma panel - Appreciate heme-onc consult - FOB studies  - Review w/ doctor today for significant findings, otherwise patient will need a BM biopsy, especially after results of labs.  Scheduled for next Tuesday with him.   - Per son, patient has significant FH of leukemia.        Acute CHF (congestive heart failure) Echo is reviewed from 1/27/22 and shows normal EF of 60% w/ normal diastolic and reasonable valve function.     Likely high-output CHF d/t pt's profound anemia, appears subjectively improving daily with negative fluid balance and weight and RA oxygen requirements.        - DC home on Lasix 20 mg daily, Kdur 20 meq daily, and Metoprolol XL 50 mg daily.    COVID-19 Asymptomatic Pt is covid positive by PCR with no associated symptoms at this time. D-dimer elevated to 1410, CRP 3.4, ferritin 709, LDH 148. No current intervention needed do to asymptomatic nature of infection. Will consider adding anticoag/antiplatelete for elevated D-dimer, but not until anemia stabilizes.  Venous Dopplers US of BLE negative for DVT Inflammatory markers improving CT reviewed with bilateral atypical pneumonia.   Recheck CXR reviewed.     Type 2 diabetes mellitus, with long-term current use of insulin Endotool started on 1/27 and continue to 1/29 and DC'ed evening of 1/29 Back on Lantus and basal bolus coverage which appears to be working well.   Continue carb controlled diet.  DC home on NPH and short acting regimen as prior to admission.      Paroxysmal atrial fibrillation Reported history, pt's CHADS2 score of 6 indicates moderate-high risk of embolic event. Pt on beta blocker at home, but this score indicates need for antiplatelet or anticoag in addition. In NSR at this time. - Continue metoprolol 25 q12h - Consider beginning anticoag of some kind once Hb becomes stable/once r/o GI bleed and platelet count is above 50 - Hold aspirin at discharge.     CAD (coronary artery disease) - stable Reported history.  Receives aspirin, beta blockade, statin, and p.r.n. nitrates as outpatient.  No current signs symptoms of coronary ischemia in spite of severe anemia. - Continue metop as above - ASA remains on hold with thrombocytopenia   HTN (hypertension) - stable On ACEi, beta blocker, hydrochlorothiazide, and amlodipine as outpatient.  Stable BP for last 3 days - Continue metoprolol and Lasix after discharge.   - May consider restarting other antihypertensives if BP become elevated after discharge and follow up with PCP next week. - Pt's significant antihypertension regimen indicates possible secondary etiology, consider additional workup after discharge DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Thrombocytopenia AKI (acute kidney injury) Pancytopenia Acute anemia COVID-19 Pancytopenia, acquired HOSPITAL COURSE: 77 y/o male widowed community dwelling patient presented to hospital ER feeling very dizzy and short of breath.  Symptoms were progressive.  He was found to have a hemoglobin of 4.3.  Because he was going to be admitted to the hospital, the patient was tested for COVID despite no specific symptoms for COVID 19 and tested positive via PCR.  The patient was placed in respiratory isolation.  The patient had no other COVID 19 symptoms during this admission.     His fecal occult blood was negative.  He was found to be pancytopenic.  The patient received 3 units of blood on admission.  He was monitored closely in CCU.  His anticoagulation for his atrial fibrillation will be held due to his low platelet count.  His aspirin is held as well.  His rate was controlled with Metoprolol.     The patient's platelet count and WBC were stable.  Hematology was consulted at two facilities. The first facility hematology department felt that the pancytopenia could be related to COVID and to monitor him. The doctor at the second facility hematology department wanted to rule out vitamin deficiencies and lymphoma/leukemia and myelodysplastic syndrome.  Labs were ordered.  He would like to do a bone marrow biopsy next Tuesday.  Nutritional deficiencies were ruled out.     The patient had no BRBPR or epistaxis or hematuria during this admission.  His hemoglobin did decrease during this admission. Iron studies were unremarkable.  He was given an additional 2 units of blood as he had a mild drop in hemoglobin over the course of 3 days.     The patient was seen by PT, OT who initially recommended SAR.  As the patient's blood count improved, the patient's energy improved.  PT, OT felt that he was appropriate to continue PT, OT at home.     The patient was treated for acute on chroinc CHF with preserved LVF secondary to high output failure related to his low hemoglobin.  The patient had a 2D echo showing a normal EF and normal diastolic function.  Patient's Lasix was increased to IV during admission at BID and he will be sent home on Lasix 20 mg daily and his potassium supplement daily.  He will have a BMP on Thursday 2/3/22 to follow up on his potassium and renal function with this new medication.  His diazide will be stopped.     The patient had no myocardial injury during this admission.  He had no substernal chest pain.  His statin and Metoprolol were continued, but his ASA was held due to his thrombocytopenia.   For his hypertension, his Metoprolol was continued, but all of his other home antihypertensives were not resumed after admission or after discharge.  Medications that were not resumed include Cozaar, HCTZ, and amlodipine.  SN is asked to check the patient's blood pressure and call his PCP for medication adjustment.     As discussed with doctor, the patient needs a follow up CBC this Thursday and will have an appointment with him the following Tuesday.  He will have a bone marrow biopsy after that appointment.     For an asymptomatic patient with COVID 19 positivity, the regulatory authority recommends quarantine for 5 days after + test.  He will be out of quarantine tomorrow.  He was given information regarding this. He will need a COVID 19 booster, but is otherwise up to date.    He will follow up with his PCP in 1 week to follow up on his hypertension and a fib and diabetes.  No change to his outpatient regimen for his diabetes was made.  He was seen by the dietician for his diabetes.      CONSULTS / RECOMMENDATION: Doctor of hematology regarding Pancytopenia.  Possibly COVID 19 related, but more likely myelodysplastic syndrome.  Labs ordered to rule out nutritional etiologies and Leukemia/Lymphoma.  He will have a bone marrow biopsy next Tuesday at doctor's office.   INPATIENT PROCEDURES: 2 units of blood (pRBC's) transfused on 1/30/22 3 units of blood (pRBC's) transfused on 1/26/22 BP 125/96  | Pulse 68  | Temp 36.4 °C (Oral)  | Resp 23  | Ht 1.676 m  | Wt 72.1 kg  | SpO2 100%  | BMI 25.66 kg/m²    Physical ExamVitals and nursing note reviewed.  Constitutional:    General: He is not in acute distress.    Appearance: He is normal weight. He is not toxic-appearing or diaphoretic.  HENT:   Nose: Nose normal. No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear. No oropharyngeal exudate or posterior oropharyngeal erythema.  Eyes:   General: No scleral icterus.    Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:   Comments: JVD normal Cardiovascular:   Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:   Effort: No respiratory distress.     Breath sounds: No stridor. No wheezing, rhonchi or rales.  Abdominal:   General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:   Cervical back: No tenderness.     Right lower leg: No edema.     Left lower leg: No edema.  Lymphadenopathy:   Cervical: No cervical adenopathy.  Skin:  General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is pale (resolving). Skin is not jaundiced.     Findings: Bruising present.  Neurological:   General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.     H&P:  ASSESSMENT / PLAN: 1.) Acute Anemia; question the etiology. No signs of bleeding, heme test negative. He is getting 3 units of blood then will recheck hemoglobin. Heme test negative. He is having some mild abdominal pain. I am going to get a CT scan of his abdomen and pelvis.    2.) COVID: newly diagnosed today. He is really not having any symptoms so will hold off on starting any new medications   3.) DM: monitor blood sugars Ac/HS and start SS insulin   4.) A-fib will hold anticoagulation   5.) DVT prophylaxis: no anticoagulation   6.) Code status DNR per the patient's wishes   This H&P was accomplished utilizing telemedicine services at Hospital. Assistance for bedside assessment was carried out interpreted and reported to me by the bedside nurse. Time spent educating, interviewing the patient, reviewing the chart and coordinating care equals 50 non continuous minutes.  HISTORY OF PRESENT ILLNESS: Patient is a 77 y.o. male who presents today secondary to feeling dizzy. He has a known history of Hypertension, Diabetes and heart disease. He presented to the ED today secondary to feeling dizzy. Upon his arrival he was found to have COVID. He denies fevers or chill, or SOB. He reports he has a decreased appetitive. He was found to have a hemoglobin of 4.3. He denies any bleeding. Denies blood in his bowel movements. He is on Eliquis at home. He is reporting some mild abdominal pain. He is being admitted for further work up. Review of Systems Constitutional:  Positive for appetite change and fatigue.  HENT: negative.  Eyes: Negative.  Respiratory:  Negative.   Cardiovascular:  Negative.  Gastrointestinal:  Negative.  Genitourinary:  Negative.  Musculoskeletal:  Negative.  Neurological:  Positive for dizziness.  Endo/Heme/Allergy:  negative.  Psychiatric/Behavioral:  Negative.  Skin:  Negative.  OBJECTIVE: BP 130/70  | Pulse 100  | Temp 36.9 °C (Oral)  | Resp 20  | Wt 79.4 kg  | SpO2 97%  | BMI 28.25 kg/m²    Physical Exam Constitutional:      Appearance: Normal appearance.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal.     Tenderness: There is abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.