Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Blood gases abnormal, Blood pH increased, Blood sodium decreased, Blood urea normal, C-reactive protein increased
Clinical narrative: Patient is a 77 y.o. female patient, DO with history of cataract, HTN who presents as transfer from alternate ED for SOB 2/2 recent COVID 19 infection as direct admit to our facility.   COVID-19 Infection Acute respiratory failure with hypoxia Superimposed bacterial pneumonia Presumed COPD, not in acute exacerbation AF, WBC 20-- >11.4, PCT 2.66, CRP 346.7; needed 3 L NC but now on RA 3/17: Positive COVID test, completed OP course of paxlovid 5 days VBG at Hospital: ph 7.45, pCO2 36.7, pO2 27, hCO3 25.7 CTPA at ER: No evidence of central PE. Moderate centrilobular emphysema Blood cultures 3/27 NGTD ID following; started decadron, rocephin, azithromycin 3/27 On 2L NC this AM. Home O2 eval prior to discharge Recommend OP PFT and OSA eval Home with albuterol inhaler Continue steroids for total 10d course. Will transition to PO abx   Liver lesion Branched portal vein thrombosis Found incidentally on imaging. No abdominal complaints or hx of liver disease. LFTs normal. GGT 49. ALP 80. iCa 4.0 CTAP 3/27: Abnormal, subtle 2 cm area of decreased attenuation within the dome of the liver concerning for hepatic tumor AFP, hepatitis negative MRI liver: branch portal vein thrombosis w/ mild associated inflammation. Few small rounded foci of nonenhancement contiguous with the thrombosed veins in the peripheral liver dome which would make tiny developing abscesses difficult to exclude.  No drainable abscess. Small hemangioma in anterior right hepatic lobe Hypercoagulable panel ordered. Thrombosis likely 2/2 COVID, but cannot exclude underlying disorder. No hx of blood clots, prolonged bleeding, or fmhx. GI and hematology following, recommend initiating anticoagulation, heme consult, repeat MR towards the end of the week Heme consulted, JAK2, BCR-ABL, lupus anticoag, cardiolipin ab, beta-2 glycoperotein ab ordered. Initiated heparin gtt 3/28. Will hold on transition to DOAC pending imaging results Hypercoag work up negative so far except Factor VIII of 285, antithrombin III of 81 MR liver 3/30: Re-demonstration of thrombosis of RPV branches.  Areas of hypoenhancement are less conspicuous and are inconsistent with abscesses. May represent areas of improving periportal inflammation. Will transition to DOAC 6 months. Close f/u with GI and PCP   Pulmonary nodule History of tobacco use Incidently found on imaging. Hx of distant tobacco use. On RA at home CTPA: Small 4 mm left upper lobe pulmonary nodule Recommend interval f/u CT in 12 months   Bilateral renal cysts Incidently found on imaging. No hx of renal dx or symptoms Cr 0.69 on admission. BUN 12 CT: simple 2 cm left renal cyst  MR: left renal cyst 2.5 cm without evidence of internal enhancement and there are multiple small bilateral renal cysts which are too small to characterize but not overtly suspicious No interventions indicated Continue to monitor kidney function   Pancreatic cystic lesions Incidentally found on imaging. No hx of pancreatitis, jaundice, weight loss, anemia, or abdominal complaints. Abd S, NT, ND, w/ no palpable mass MR: Sub-centimeter cystic lesions in the pancreas may represent dilated ductal side branches or side branch IPMNs.  No main ductal dilatation Recommend MRI/MRCP 2 years   Hyponatremia Na 122 on arrival now 136; continue to hold HCTZ   Essential Hypertension Controlled; continued home clonidine but hold HCTZ