Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Malnutrition, Open reduction of fracture, Pain in extremity, Pancytopenia, Pasteurella infection
Clinical narrative: Patient is a 70 y.o. male patient of CNP with history of Stage IV small cell lung cancer, brain metastasis, seizures, CAD, alcohol use, tobacco use, COPD, GERD, CVA, left hip fracture and ORIF within the past 3 months presented with fall, leg pain, shortness of breath. He presented today with complaint of blacking out, fall, and shortness of breath. He notes that he has been having multiple syncope-like events for likely the last several months which he describes as darkening vision and loss of consciousness, which he states happen with positional changes or while walking. He is unable to quantify how many or how long each episode lasts, and the episodes are unwitnessed.  He states that he has been having increased fatigue and congestion which started on 11/6 with addition of cough with green sputum production and shortness of breath starting 11/7. He notes a fall on 11/6 as well but is not sure if it is related to his syncope-like events. With his fall, he reports pain in the back of the head and left hip.   In the ED vitals are as follows, temperature 97.6, blood pressure 94/57, heart rate 75, RR 21, and oxygen saturation of 98% on 3L. He did have an episode of tachycardia at 140 bmp around 1445, but resolved after administration of IFV. Labs results were significant for hyponatremia (131), AKI with cr 1.38 and prerenal ratio at 52.2, pancytopenia (WBC 1.64, Hgb 6.8, Plt 30), elevated D-dimer (3.99), elevated CRP (347.0), elevated BNP (1,371). The rest of the CBC and CMP were within normal limits. Troponin 15/19. COVID Positive, Flu swab negative. Chest x-ray: Patchy airspace disease and nodularity in the right midlung. CTA-PE Ill-defined spiculated mass within the posterior segment of the right upper lobe, minimally increased in size.  Stable mildly enlarged right hilar lymph nodes.  Slight interval decrease in size of mediastinal lymph nodes. Dependent secretions within the distal trachea and bilateral mainstem bronchi.  Mild airspace opacification dependently within the right upper and right lower lobes suggesting prior aspiration. Severe emphysema. Severe coronary arterial calcifications.  Stable fusiform dilatation of the ascending thoracic aorta. Extensive stool burden throughout the colon indicating constipation.  Prostatic enlargement. Subcentimeter left renal cyst. CT Head, XR hip/pelvis/femur were non-acute. Patient was given 1500 ml IVF, cefepime 2g, SoluMedrol 80mg. Patient admitted for observation.    Clinical Summary Patient tested positive for covid 11/7 with onset of symptoms 115.  He completed a course of remdesivir and was on dexamethasone and has been weaned back to baseline oxygen.  Patient's COPD exacerbation as likely secondary to a combination of covid as well as a component of aspiration pneumonia.  Patient had 2 out of 2 blood cultures return with pasteurella multocida and will need a total of 14 days of augmentin.  Patient also had an AKI that resolved and pancytopenia, likely secondary to chemotherapy, that has improved.  Patient will be discharged home with home health and augmentin 875mg BID x12 days with instructions to follow up with PCP, oncology, pulmonology, and urology.  VS and labs have been stable otherwise Discharge diagnosis COVID-19  COPD with exacerbation Chronic Hypoxic Respiratory Failure Aspiration Pneumonia Pasteurella Bacteremia Sepsis Pancytopenia AKI Urinary Retention  Hx of BPH  Hx of Anterior Urethral Stricture New Onset Atrial Fibrillation with RVR  Hypotension Stage IV Small Cell Lung Cancer Known Brain Metastasis  Elevated Alkaline Phosphatase  Seizures  Generalized Weakness Frequent Falls Syncope Left Thigh Hematoma  Chronic Alcohol Use Mild Hyponatremia  Hypertension GERD  CAD  Mood disorder Moderate Aortic Stenosis Severe Malnutrition with Cachexia  Hx CVA  Chronic Hep C, uncompleted treatment