Age: 86.0
Sex: F
Vaccine: COVID19
Symptoms: Septic embolus, Soft tissue necrosis, Staphylococcal bacteraemia, Thrombosis, Transfusion
Clinical narrative: Hospitalized (1.13.22 - still admitted currently); COVID-19 positive (1.13.22); Fully vaccinated -moderna x2 1/13/22 H&P: CHIEF COMPLAINT: Hyperkalemia    ASSESSMENT / PLAN: * Hyperkalemia Assessment & Plan - Due to renal failure - EKG with ST segment depressions in the lateral leads, but with normal QRS and T waves - Received 1g calcium gluconate, D50 and insulin, and 1 amp bicarb in the ED as well as almost 2L IVF (1st liter was NS) - Repeat K 5.6, though concerned that this is just shifting potassium and does not represent true lower of K - Nephrology consulted and following - Trend BMP q6h - May need urgent HD tonight and if so will place temp HD line - Will give D50 and insulin in additional 2 more amps bicarb and start bicarb drip - Repeat EKG   Aortic stenosis Assessment & Plan - Moderate based on last echo done in 2021 - No acute issues   COVID-19 virus infection Assessment & Plan - Per grandaughter, has been coughing for the last 3 days but today had more dyspnea which is likely due to renal failure and sepsis more than due to COVID - CXR without pneumonia, though imaging is poor quality - I do not think she has much oxygen requirement (she is satting 98% on 6L), therefore will hold off on additional steroids for now. She did receive 1 dose of Deadron in the ED   Acidosis Assessment & Plan - Due to renal failure - Currently awake and mentation normal, protecting airway - Treatment for renal failure as written. Trend VBG q6h   Acute kidney injury superimposed on chronic kidney disease (HCC) Assessment & Plan - Baseline GFR around 15 - Now with Cr of 6, K of 7, bicarb of 13, and BUN of 124 - CBC with diff shows bandemia and UA with high WBC - Etiology due to either obstructive uropathy, sepsis, or prerenal  - Will give IVFs with bicarb drip only for now (received 2L in ED) - Foley placed but not much urine output currently - Check bedside renal US and KUB for obstructive uropathy - Strict Is/Os - Trend VBG with BMP   HFrEF (heart failure with reduced ejection fraction) (HCC) Assessment & Plan - Last echo in 2021 shows EF of 44%. Has previously needed thoracenteses for pleural effusions - Will need to be mindful of volume resuscitation given renal failure   Sepsis (HCC) Assessment & Plan - Suspect urinary source - Received azithro, ceftiaxone, vanc, and pip/tazo in the ED - Will continue cefepime and daptomycin given prior infection with VRE - Follow urine and blood cultures   Rheumatoid arthritis Assessment & Plan - On low dose prednisone at home (5mg) - Normotensive here, but low threshold to start stress dose steroids - Restart steroids when able to take po Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 86 y.o. female who presents today with renal failure.   All history obtained from patient's granddaughter. Patient was in her usual state of health until 3 days ago when she began having a cough. No fevers, abdominal pain, hematuria, confusion, weakness, decreased appetite, n/v/d. EMS was called by granddaughter yesterday due to cough but vital signs were all within normal limits. This was suspected to be COVID. Today things progressed with symptoms of dyspnea and weakness so patient was brought to the ER where she was found to be COVID positive and in renal failure with K of 7.3, Cr of 6, BUN of 124, and blood gas with pH of 7.15. She was subsequently admitted to the MICU.   Currently patient denies any chest pain, dyspnea, abdominal pain, or confusion. States she would like to have dialysis if needed because she wants to be alive for her family. Patient Active Problem List Diagnosis ? Rheumatoid arthritis ? Hyperlipidemia ? Primary hyperaldosteronism (HCC) ? Chronic kidney disease (CKD), stage IV (severe) (HCC) ? Aortic stenosis ? Female stress incontinence ? Chronic obstructive pulmonary disease, unspecified COPD type (HCC) ? Rheumatoid arthritis involving multiple sites with positive rheumatoid factor (HCC) ? Secondary hypertension ? Long term current use of systemic steroids ? Cholelithiases ? Sepsis (HCC) ? Other insomnia ? Slow transit constipation ? HFrEF (heart failure with reduced ejection fraction) (HCC) ? AFIB vs MAT with rapid ventricular response ? Nonischemic cardiomyopathy (HCC) ? Chronic combined systolic and diastolic heart failure (HCC) ? Deep vein thrombosis (DVT) of femoral vein of left lower extremity (HCC) ? Anemia of chronic disease ? Hyperkalemia ? Acute kidney injury superimposed on chronic kidney disease (HCC) ? Acidosis ? COVID-19 virus infection ? Aortic stenosis OBJECTIVE: BP 117/57  | Pulse 96  | Temp 37.2 °C  | Resp 21  | Ht 1.549 m  | Wt 62.8 kg  | SpO2 96%  | BMI 26.16 kg/m²  FIO2 (%): 45 % Physical Exam    Elderly female, no distress HFNC falling out of nose and O2 sats remain 94% Clear lungs anteriorly Heart RRR, unable to assess for murmurs No peripheral edema Dark bloody urine in foley bag, minimal amount Pain over RUQ, no tenderness over bladder Awake, talkative Dry mucous membranes  1/25/22  progress note:                                                Date of admission: 1/13/2022 Date of encounter: 01/25/2022  ASSESSMENT/PLAN: Patient appears to be totally alert and oriented today.  Discussed with case manager plan is for her to go to the skilled nursing facility at the belt line which accepts COVID patients.  Has some abdominal pain off and on.  Which responds to Tylenol.  Has been seen by GI no further workup is recommended.   I attempted to call the patient's granddaughter at 1:00 p.m. on a mobile phone again today and left a message.    Patient presented with lethargy and shortness of breath.  She initially required the oxygen however now she is on room air.  Patient presented with hyperkalemia secondary to worsening renal functions however it corrected medically and she did not require hemodialysis.  The patient noted to have lower GI bleed and required blood transfusion.  She has been seen by GI who do not recommend any intervention at this time.  I attempted to reach out to the patient's granddaughter at 1:00 p.m. again today on her mobile phone and I did leave a message.    1. Anemia of acute blood loss. Will continue to monitor hemoglobin and transfuse as needed. Patient has been seen by GI who do not plan to do any scopes at this time.  2. COVID infection. Continue dexamethasone. Not a candidate for remdesvir due to low GFR.  3. Rheumatoid arthritis. Denies any symptoms at this time will continue steroids.  4. Acute on Chronic renal disease. Presented with hyperkalemia that has resolved. Nephrology following. Will monitor creatinine closely and avoid nephrotoxic agents.  5. New onset atrial fibrillation with RVR. On Toprol-XL. On apixaban.  6. Acute on chronic hypoxic respiratory failure. Oxygen requirements have improved to room air currently. Will continue to monitor.  7. MSSA bacteremia. Seen by Infectious Disease, remains on cefazolin to complete 6 weeks. Found to have necrotizing patchy lesions in the brain with septic emboli.  Likely the source of infection. Cystitis present on admission cultures grew Enterococcus.   PICC line is in place.  8. Deconditioning. Skilled nursing facility recommended by OT and PT. Case manager is working on transfer.  9. Code status.   Full code.  10. DVT prophylaxis.   On apixaban.  11. Leukocytosis.   Persists.  Unclear etiology.  Patient also on steroids. With MSSA bacteremia. Continue antibiotics.  12. Abdominal pain. CT abdomen was not helpful with any pathology. GI consulted for recommendations.   No plans for any intervention per GI.  13. Transient altered mental status. Resolved.   CT of the brain did not show any changes.   CC: SHORTNESS OF BREATH (two days with shortness of breath, on oxygen at home , cough and congestion, fatigue. )  SUBJECTIVE: The patient is a 86-year-old lady who presented to the hospital due to cough and lethargy.  The patient does not speak Spanish therefore an interpreter service was used.  She has a past medical history which is significant for chronic kidney disease stage 4 with baseline creatinine of 2143, rheumatoid arthritis on chronic prednisone, nonischemic cardiomyopathy with EF 44%.  At time of presentation the patient was noted to be hypoxic and was placed on high-flow nasal cannula.  She was found to be positive for COVID-19.  X-ray chest showed possible CHF versus pneumonia.  UA was suggestive of urinary tract infection.  She was brought into the intensive care unit as a potassium was found to be 7.3 with a creatinine of 6.3 and BUN of 124. Plans were made for emergent hemodialysis however repeat potassium showed 5.6 after medical treatment for hyperkalemia.  She was started on prednisone for COVID pneumonia with an increasing dose that she is on prednisone for rheumatoid arthritis.  She was the subsequently weaned down to 4 L by nasal cannula.  The patient the will also started on a heparin drip due to lower extremity DVT, AF fibrillation with RVR.  Initially was started on a Ancef per Infectious Disease later antibiotics were broadened to IV cefepime and Flagyl due to worsening pneumonia.  She was found to have MSSA bacteremia.  Repeat cultures have been negative since the 15th January 2022. She was followed by Nephrology and her renal functions have improved.  The patient was noted to have episode of blood clot in the stool and the hemoglobin came down requiring blood transfusion.  GI was consulted they recommended against EGD at this time.    OBJECTIVE: BP 139/67  | Pulse 83  | Temp 36.3 °C (Oral)  | Resp 18  | Ht 1.549 m  | Wt 63.7 kg  | SpO2 98%  | BMI 26.53 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: She is ill-appearing.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     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:     Breath sounds: Wheezing and rhonchi present.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal.     Palpations: Abdomen is soft.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.