Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: White blood cell count increased
Clinical narrative: Date of Admission:  12/5/2023    Date of Discharge:  12/13/2023      Pending Study Results at Discharge: Cultures   Issues to be Addressed in Follow-up:   1) Continue IV antibiotics as directed by ID, end date 1/16/24   2) Patient has growing renal mass, consult placed for Urology follow up as outpatient   3) Continued resolution of COVID pneumonia   4) Continued rate control, amiodarone started this admission   5) Patient will need continued weaning off of Midodrine as outpatient   6) weekly labs ordered while on IV antibiotics to be drawn and faxed to backup clinic.   Reason for Hospital Admission (Admitting Diagnosis):  severe sepsis secondary to covid 19/CAP, afibr RVR    HPI on admission:    Patient is a 76 Y  female with history of left clear-cell renal carcinoma, iron deficiency anemia, hypertension, CAD status post PCI 04/2014, DM 2 who presents secondary to fever and altered mental status.   History obtained predominantly from chart review as patient is a poor historian.   History of Present Illness as per Dr. in the ED:  Patient is a 76 Y female with PMH of DM2, HTN, CAD, dementia, stroke, cachexia who presents to the Emergency Department for altered mental status and fever. Family reports fever for a couple days, then today was found to be profoundly altered. EMS reports HR in the 150s, normal BP, glucose 376. On arrival she is not able to answer questions, moans to pain. Further history unavailable. Family does report she is full code. Family states she has not recently had COVID.   Patient is unsure of why she is in the emergency department.  Endorses dry cough for the last couple of days.  Denies any rhinorrhea, nasal congestion, sore throat, odynophagia, shortness of breath, chest pain, abdominal pain, constipation or diarrhea.  Patient denies any nausea, vomiting, chills, diaphoresis, appetite changes or fatigue.   ED course: Blood cultures, x-ray chest, head CT, LR 2L bolus, vancomycin IV, Zosyn IV, amiodarone drip, Decadron 6 mg IV, CT chest   Hospital Course:   Patient initially presented with fever altered mentation A-fib with RVR acute hypoxemic respiratory failure and hypotension, was found to have acute COVID-pneumonia, started on remdesivir and dexamethasone as well as broad-spectrum antibiotics due to suspicion of concurrent bacterial pneumonia.  For A-fib RVR patient was started on amiodarone drip which was transitioned to oral amiodarone after load.  Blood cultures grew back positive for MSSA in 1 out of 2 bottles.  After ID consultation, the patient was switched to ampicillin-sulbactam which was then switched to cefazolin for planned 6 weeks of therapy due to suspected septic emboli to the lungs.  Primary source was not identified.  Echocardiogram did not show evidence of SBE.  Patient was transferred out of the ICU on 12/9/2023 on oral midodrine.  Repeat blood cultures were negative and a PICC line was placed on 12/12/2023.  At the direction of ID, patient was declared stable for discharge to skilled nursing facility to complete IV antibiotic course plan for 6 weeks.  Patient finished remdesivir course while inpatient.  Patient will continue isolation until the isolation date at skilled nursing facility.  Abdominal CT also showed enlarging renal mass when compared to prior.  consult was sent to urology for outpatient follow-up.  Patient will follow-up with skilled nursing facility physician for weaning off midodrine, continued improvement of respiratory status, and resolution of infectious symptoms.  Weekly labs were ordered and will be faxed to clinic.   Significant Findings:    Please see above   Hospital Course By Problem: Patient Active Hospital Problem List:  SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION (8/4/2020)  ACUTE HYPOXEMIC RESPIRATORY FAILURE (8/2/2020)  COVID-19 DISEASE (12/5/2023)  COVID-19 PNEUMONIA (12/5/2023)  PLEURAL EFFUSION (12/5/2023)  GRAM POS BACTEREMIA (12/12/2023)   Assessment:  - Doing well today - BP 100/67  | Pulse 92  | Temp 97.7 °F (36.5 °C)  | Resp 16  | Ht 5' 1"  | Wt 50.8 kg (112 lb)  | SpO2 97%  | Breastfeeding No  | BMI 21.16 kg/m²   Lab Results Component Value Date   WBC COUNT 14.5 (H) 12/12/2023    Lab Results Component Value Date   Hgb 8.1 (L) 12/12/2023    Lab Results Component Value Date   ALT 10 12/10/2023   AST 16 12/10/2023   ALKALINE PHOSPHATASE 152 (H) 12/06/2023   Bilirubin, total 0.3 12/10/2023   Amylase 79 04/09/2014   Lipase <3 12/05/2023    Lab Results Component Value Date   Lactate, ser/plas 1.7 12/07/2023   Lactate, ser/plas 1.7 12/05/2023   Lactate, ser/plas 1.7 07/02/2023      Lab Results Component Value Date/Time   CORONAVIRUS COVID DETECTED (A) 12/05/2023 02:54 PM   No results for input(s): "UPH", "USG", "UAGLU", "UKET", "UABILI", "UPROTEIN", "ULEUKESTER", "UNITRITE", "URBC", "UWBC", "UBACT" in the last 72 hours. - Blood Cultures 12/5/23: MSSA isolated - Blood Cultures 12/6/23: NG 5 days - Blood Cultures 12/9/23: NG 3 days - Per ID: MSSA bacteremia, source unclear, Can switch Unasyn to Cefazolin 2g IV Q8H, anticipate 6 week total course, s/p 5 days remdesivir, continue wound care/nutrition, urology to f/u L RCC, OK to place PICC    Plan:  - Continue Cefazolin 2g IV Q8H for 6 weeks total - s/p 5 days Remdesivir  - s/p PICC placement - Continue O2 support, wean as able   HTN (5/8/1995)  CAD (CORONARY ARTERY DISEASE) WO ANGINA (1/8/2003)  ATRIAL FIBRILLATION W RAPID VENTRICULAR RESPONSE (12/5/2023)  ELEVATED TROPONIN I (12/5/2023)  TYPE 2 MI (12/12/2023)  HTN (HYPERTENSION) (6/21/2006)   Assessment:   Vitals:   12/12/23 0438 12/12/23 0500 12/12/23 0855 12/12/23 1131 BP: 114/85   92/51 98/56 Pulse: 96 102 102 105 Resp: 18   18 18 Temp: 98.6 °F (37 °C)   98.5 °F (36.9 °C) 97.6 °F (36.4 °C) SpO2: 93%   97% 98% Weight:         Height:              Plan:  - s/p Amiodarone load IV - Change to Amiodarone 400 mg QD on discharge - Continue ASA 81 mg QD, Atorvastatin 80 mg QD, Metoprolol 12.5 mg BID - Continue Midodrine 5 mg TID, wean off as outpatient with continued treatment of infection - Will need to have risk/benifit discussion with family regarding anticoagulation for stroke risk reduction.   DM 2 W DYSLIPIDEMIA (11/29/2007)  DIABETES MELLITUS   Assessment:   Lab Results Component Value Date   Hgb A1c % 11.1 (H) 12/06/2023    Lab Results Component Value Date   GLUCOSE, RANDOM 74 12/12/2023   GLUCOSE, RANDOM 40 (A) 12/11/2023   GLUCOSE, RANDOM 102 12/10/2023    GLUCOSE, BLOOD, GLUCOMETER Date/Time Value Ref Range Status 12/12/2023 1120 101 60 - 159 mg/dL Final 12/12/2023 0852 82 60 - 159 mg/dL Final 12/11/2023 2225 128 60 - 159 mg/dL Final     Comment:     Hour of Sleep 12/11/2023 1849 163 (H) 60 - 159 mg/dL Final     Comment:     Pre-meal 12/11/2023 1635 168 (H) 60 - 159 mg/dL Final 12/10/2023 2115 140 60 - 159 mg/dL Final      Plan:  - Continue ISS - Continue NPH 10 U QAM, 5 U QPM - Resume Metformin 1000 mg QHS, Glipizide 5 mg QD - Continued optimization as outpatient     ACUTE POSTTRAUMATIC STRESS DISORDER (10/22/2015)  MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE (11/29/2007)  GENERALIZED ANXIETY DISORDER (11/9/2019)  MAJOR NEUROCOGNITIVE DISORDER DUE TO UNSPECIFIED DISEASE (UNSPECIFIED DEMENTIA) (11/9/2019)  ADJUSTMENT DISORDER W MIXED ANXIETY AND DEPRESSED MOOD (6/9/2021)   Assessment: Noted, complicated by above    Plan:  - Continue Donepezil 10 mg QD - Continue Seroquel 50 mg QHS - Continue Trazodone 200 mg QHS - Continue Venlafaxine 225 mg QD - Resume Gabapentin 300 mg TID as outpatient   KIDNEY CANCER, LEFT KIDNEY (1/9/2022)   Assessment: noted, growing on new imaging this admission   Plan: f/u urology as outpatient (consult placed)       Complications:  None   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION   ? GRAM POS BACTEREMIA   ? COVID-19 DISEASE   ? COVID-19 PNEUMONIA   ? PLEURAL EFFUSION   ? ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? TYPE 2 MI   ? ATRIAL FIBRILLATION W RAPID VENTRICULAR RESPONSE   ? ELEVATED TROPONIN I   ? CAD (CORONARY ARTERY DISEASE) WO ANGINA       2/17/2022: Chronic established diagnosis. Briefly reviewed plan today, cont current regimen.      Cath 4/17/14 severe disease in the LAD and LCx, and mild to moderate disease in the RCA; the LMCA is without significant luminal disease; the prior stent in the LAD is widely patent stent placed to LAD and LCx     ? HTN       2/17/2022  Briefly reviewed medications/plan today: Cont current regimen   HTN-Established diagnosis BP Goal: <139/89 Control: Well controlled with current meds -------------------------------------------- Current Meds: Beta-Blocker Adherence: Always takes meds Meds tried in past and stopped: ACE, HCTZ, Beta-Blocker and Hydralazine Last medication adjustment: No changes today -------------------------------------------- Risk (A-Risk): 26.9%   Labs: Reviewed on 11/2021 next due: 11/2022 Next visit due: 6 months OV/Routine ----------------------------------------------  Lab Results Component Value Date   Creatinine 0.62 11/24/2021     @@   Lab Results Component Value Date   Hgb A1c % 6.6 (H) 10/30/2020      Lab Results Component Value Date   Low density lipoprotein calculated NOT DONE 01/14/2015   Low density lipoprotein direct 102 04/27/2017   Cholesterol 132 12/06/2020   Triglyceride 598 (H) 01/14/2015   HDL 43 (L) 12/06/2020        BP Readings from Last 3 Encounters: 12/20/21 115/78 11/24/21 122/68 10/21/21 139/67   --------------------------------------------- Medication Plan:  Start ACE/HCTZ (Replace ACE w/ ARB if intolerant)-- >Add CCB (Amlodipine 2.5..>5-- >10mg)-- >Replace HCTZ w/ Chlorthalidone 25mg-- >Spironolactone 12.5-- >25 (unless pt not on thiazide,GFR <60 or K>4.5.  If not able to do Spironolactone-- >Atenolol 25-- >50mg.  Titrate to goal BP and HR >55 Education:  Handout/discussion of DASH, weight reduction, moderation of EtOH, salt intake, regular exercise 150min/week, track/monitor home BPs and goals       ? ACUTE POSTTRAUMATIC STRESS DISORDER   ? DM 2 W DYSLIPIDEMIA       2/17/2022: Chronic established diagnosis. Briefly reviewed medications/plan today, cont current regimen.   Atorvastatin 80 mg   Chronic est dx: well controlled though overdue for labs A1c:    Lab Results Component Value Date   Hgb A1c % 6.6 (H) 10/30/2020     Labs/Follow up due: now Meds: metformin and glipizide  BPs: well controlled  Micoalb: Neg  Cr:   Lab Results Component Value Date   Creatinine 0.62 11/24/2021     Lipids: on statin Eye exam: UTD  Foot: checks daily ACE: on ACE Risk (A-Risk): 26.9%   ASA:  Pneumovax:   Last Vacc Pneumococcal Polysaccharide :  12/20/17 (VACC PNEUMOCOCCAL POLYSACCHARIDE, 23 VALENT)         ? ADJUSTMENT DISORDER W MIXED ANXIETY AND DEPRESSED MOOD        6/9/2021 - DOV Pt's daughter has been critically ill and outcome is not known.  Will book with behavioral medicine to discuss further.         ? MAJOR NEUROCOGNITIVE DISORDER DUE TO UNSPECIFIED DISEASE (UNSPECIFIED DEMENTIA)       2/17/2022 Stable, will continue to monitor      ? GENERALIZED ANXIETY DISORDER       2/17/2022: Chronic established diagnosis. Briefly reviewed plan today, cont current regimen.          ? MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE       7/19/2023: Chronic established diagnosis. Briefly reviewed plan today, cont current regimen.          ? KIDNEY CANCER, LEFT KIDNEY       2/17/2022 Pt plans to monitor for now     1/4/22 with Urology: Called pt and her daughter in f/u to discuss renal bx results:                        Surgical Pathology Report      FINAL PATHOLOGIC DIAGNOSIS  LEFT ADRENAL MASS, BIOPSY:  - FEATURES COMPATIBLE WITH CLEAR CELL RENAL CELL CARCINOMA  MORPHOLOGICALLY, PROVISIONAL WHO GRADE II.    We discussed that the kidney mass is malignant. We discussed treatment options, including partial or radical nephrectomy (open vs laparoscopic or robotic for either), active surveillance or thermal ablative techniques (this tumor is too large for cryoablation). I explained that partial nephrectomy is usually preferred modality, when feasible, as it preserves the most kidney and has comparable outcomes to radical nephrectomy, from an oncologic control standpoint, but given pt's health issues, observation may be preferable. I reviewed the risks and benefits of the procedures in detail. After discussion, they wish to consider options and let me know how they wish to proceed.      Resolved Hospital Problems No resolved problems to display.     Primary Procedures:  None      Secondary Procedures: CRITICAL CARE PROCEDURE   Consults:  infectious disease   Condition on Discharge:  Stable    Code Status at Time of Discharge: Full Code     Discharge Disposition:  SNF   Discharge Medications: Medications, instructions, follow up information: See patient instructions (or SNF Admission orders if applicable).                      Note Details  File Time 12/13/2023  3:53 PM Author Type PHYSICIAN (D.O.) Status Signed Specialty Hospital Medicine Admit Date 12/5/2023  ED to Hosp-Admission (Discharged) on 12/5/2023  ED to Hosp-Admission (Discharged) on 12/5/2023   Detailed Report  Note shared with patient Hospital Problem List   MAJOR NEUROCOGNITIVE DISORDER DUE TO UNSPECIFIED DISEASE (UNSPECIFIED DEMENTIA)  ATRIAL FIBRILLATION W RAPID VENTRICULAR RESPONSE  GENERALIZED ANXIETY DISORDER  ACUTE HYPOXEMIC RESPIRATORY FAILURE  ADJUSTMENT DISORDER W MIXED ANXIETY AND DEPRESSED MOOD  KIDNEY CANCER, LEFT KIDNEY  COVID-19 DISEASE  COVID-19 PNEUMONIA  PLEURAL EFFUSION  ELEVATED TROPONIN I  GRAM POS BACTEREMIA  TYPE 2 MI  SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION  HTN  CAD (CORONARY ARTERY DISEASE) WO ANGINA  DM 2 W DYSLIPIDEMIA  ACUTE POSTTRAUMATIC STRESS DISORDER  MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE Care Timeline  12/06   Transferred to ICU 0015   Admitted from ED (Observation) 0015 12/07   Admitted 1115 12/11   Transferred out of ICU 1715 12/13   Discharged 1930  Discharge   SNF - Custodial Bed   SNF Orders (Printed 12/13/2023)