Age: 73.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Activated partial thromboplastin time shortened, Acute myocardial infarction, Alanine aminotransferase increased, Albumin globulin ratio decreased, Ammonia normal
Clinical narrative: 1/26/22 The patient is a pleasant 74 yr/o male presenting to the ED with fall and cough.  Patient states that last night he was trying to get out of bed and slid out of bed because he was generally weak and unable to get up.  He apparently was lying on the floor for several hours.  He did not hit his head and states he did not lose consciousness.  He is on Coumadin at this time for history of left lower extremity DVT.  He is not complaining of any particular pain on my exam but states that he has been having a cough with dyspnea over the past approximately 1 week.  No hemoptysis.  He denies having a fever.  States he is up-to-date on COVID-19 vaccinations.  He has chronic left lower extremity edema from his DVT. Review of Systems  Constitutional: Negative for activity change, chills and fever.  HENT: Negative for ear pain, congestion, sore throat, neck pain and ear discharge.   Eyes: Negative for pain, discharge and redness.  Respiratory: Positive for cough. Negative for chest tightness, shortness of breath and wheezing.   Cardiovascular: Negative for chest pain, palpitations and leg swelling.  Gastrointestinal: Negative for abdominal distention, abdominal pain, constipation, diarrhea, nausea and vomiting.  Genitourinary: Negative for decreased urine volume, difficulty urinating, dysuria, flank pain, hematuria and urgency.  Musculoskeletal: Negative for back pain and arthralgias.  Skin: Negative for color change and pallor.  Neurological: Negative for dizziness, seizures, weakness, numbness and headaches.   CBC w/Diff   Collection Time: 01/26/22  6:17 PM Result Value Ref Range   White Blood Count 3.85 (L) 4.5 - 11.0 10*3/uL   Red Blood Count 4.45 (L) 4.5 - 5.9 10*6/uL   Hemoglobin 13.0 (L) 13.5 - 17.5 g/dL   Hematocrit 38.9 (L) 41.0 - 53.0 %   Mean Corpuscular Volume 87.4 80.0 - 100.0 fL   Mean Corpuscular Hemoglobin 29.2 26.0 - 34.0 pg   Mean Corpuscular HGB Conc 33.4 31.0 - 37.0 g/dL   Red Cell Distribution Width-CV 15.1 12.0 - 16.8 %   Platelet Count 119 (L) 140 - 440 10*3/uL   Mean Platelet Volume 11.1 8.4 - 12.4 fL   Diff Type Hospital CBC w/AutoDiff (arb'U)   Neutrophils % 70.0 45 - 80 %   Lymphocyte % 16.4 15 - 50 %   Monocyte % 12.5 0 - 15 %   Eosinophil% 0.3 0 - 7 %   BASO% 0.5 0 - 2 %   Immature Granulocyte% 0.3 0.0 - 1.0 %   Nucleated RBC % 0 0 /100(WBC)   Neutrophil Abs 2.70 2.0 - 8.8 10*3/uL   Lymphocyte-Absolute 0.63 (L) 0.7 - 5.5 10*3/uL   Monocyte Absolute 0.48 0.0 - 1.7 10*3/uL   EOS-Absolute 0.01 0.0 - 0.8 10*3/uL   Basophil Abs 0.02 0.0 - 0.2 10*3/uL   Immature Granulocyte Abs 0.01 0.00 - 0.10 10*3/uL Partial Thromboplastin Time   Collection Time: 01/26/22  6:17 PM Result Value Ref Range   Partial Thromboplastin Time 38.8 (H) 25.1 - 36.5 s Protime-INR   Collection Time: 01/26/22  6:17 PM Result Value Ref Range   Prothrombin Time 25.2 (H) 10.3 - 13.3 s   INR 2.1 INR CMP   Collection Time: 01/26/22  6:17 PM Result Value Ref Range   Sodium 136 136 - 145 mmol/L   Potassium 4.8 3.5 - 5.1 mmol/L   Chloride 109 (H) 98 - 107 mmol/L   Carbon Dioxide 16 (L) 22 - 29 mmol/L   Anion Gap 11 5 - 13 (arb'U)   Glucose 158 (H) 74 - 99 mg/dL   Blood Urea Nitrogen (BUN) 25 8 - 26 mg/dL   Creatinine-Blood 1.35 (H) 0.73 - 1.18 mg/dL   BUN/Creatinine Ratio 18.5 RATIO   Estimated GFR 52 (L) >60 /1.73 m2   Estimated GFR if race >60 >60 /1.73 m2   Total Protein 7.5 6.2 - 8.0 g/dL   Albumin 3.8 3.2 - 4.6 g/dL   Globulin 3.7 1.5 - 4.5 g/dL   Albumin/Globulin Ratio 1.0 (L) 1.1 - 2.5 RATIO   Calcium 10.0 8.4 - 10.2 mg/dL   Total Bilirubin 1.8 (H) 0.2 - 1.2 mg/dL   AST/SGOT 64 (H) 5 - 34 U/L   ALT/SGPT 57 (H) 0 - 55 U/L   Alkaline Phosphatase 125 40 - 150 U/L Magnesium   Collection Time: 01/26/22  6:17 PM Result Value Ref Range   Magnesium 1.8 1.6 - 2.6 mg/dL CK   Collection Time: 01/26/22  6:17 PM Result Value Ref Range   CK 436 (H) 30 - 200 U/L Troponin   Collection Time: 01/26/22  6:17 PM Result Value Ref Range   Troponin 0.206 (HH) 0.000 - 0.034 ng/mL Ammonia   Collection Time: 01/26/22  6:17 PM Result Value Ref Range   Ammonia 45 <72 umol/L Toxicology Screen   Collection Time: 01/26/22  6:17 PM Result Value Ref Range   Acetaminophen <18.0 <18.0 ug/mL   Ethylalcohol <10 <10 mg/dL   Salicylate <5.0 2.0 - 20.0 mg/dL Urinalysis   Collection Time: 01/26/22  6:26 PM Result Value Ref Range   Color-Urine Yellow     Clarity-Urine Clear     Specific Gravity Urine 1.023 1.005 - 1.030 (arb'U)   pH-Urine 5.5 5.0 - 9.0 (pH)   Protein-Urine 50 (A) Negative mg/dL   Glucose-Urine Negative Negative mg/dL   Ketone-Urine Negative Negative mg/dL   Bilirubin-Urine Negative Negative mg/dL   Occult Blood-Urine 3+ (A) Negative (arb'U)   Nitrite-Urine Negative Negative (arb'U)   Urobilinogen-Urine Normal Normal (EhrlichU)/dL   Leukocyte Esterase-Urine Negative Negative (arb'U)   Source-Urine Urine Midstream     Reflex Microscopic? Microscopic performed     RBC-Urine 143 (H) 0 - 2 (HPF)   WBC-Urine 3 0 - 3 (HPF)   Squamous Epithelial-Urine 1 0 - 4 (HPF)   Bacteria-Urine None Seen None Seen (HPF)   Mucus-Urine TRACE (A) None Seen (LPF) Toxicology Screen, urine   Collection Time: 01/26/22  6:26 PM Result Value Ref Range   Amphetamines-Urine Scrn Negative Negative   Barbiturates-Urine Screen Negative Negative   Benzodiazepines-Urine Screen Negative Negative   Cannabinoids-Urine Screen Negative Negative   Cocaine-Urine Screen Negative Negative   Opiates-Urine Screen Negative Negative Lactic Acid   Collection Time: 01/26/22  7:22 PM Result Value Ref Range   Lactic Acid  1.5 0.7 - 2.0 mmol/L  XR Chest 1 Vw  1/26/22    IMPRESSION: 1. Hazy increased density in the lungs bilaterally may be mild edema or infiltrate  CT Angiogram Chest For PE  1/26/22   IMPRESSION: 1. Limited exam secondary to motion artifact. Heterogeneous enhancement of bilateral pulmonary arteries and veins favored to be related to timing of the contrast bolus and mixing of contrast and motion artifact. No central pulmonary embolus and no convincing peripheral embolus on this limited exam. Correlation with Doppler venous ultrasound and d-dimer levels is recommended. 2. Emphysema. 3. Noncalcified nodule in the left upper lobe measures 3 mm and not seen on the prior exam. Recommend attention on follow-up. 4. Focal atelectasis or infiltrate in the left lung base. 5. Atherosclerotic vascular calcification and coronary artery calcification without aortic dissection.  1/29/22  Discharge: Hospital Course:    The patient is a 74 year old male with past medical history of dm, dvt, chronic anticoagulation with coumadin, cirrhosis admitted for viral sepsis, covid 19. Please see h and p for details.   The following issues were addressed:   1. Viral sepsis (temp 100.6, heart rate 110), poa - blood cultures no growth to date - afebrile >24 hours   2. Covid 19 infection - vaccinated - cta chest shows no pe - covid pos 1/26/22 - procal neg - continue supportive care - needs repeat imaging as outpatient with pcp to ensure resolution   3. Acute on stage 3 ckd - 2/2 dehydration - creatinine 1.2 on 8/16/21 - creatinine 1.35 on admission - creatinine 1.2 today - needs cmp 1/31/22 with pcp   4. Elevated troponin (peak troponin 0.206) - suspect non mi elevation in setting of covid - ekg shows no acute changes - trend flat   5. Rhabdomyolysis (peak ck 1449) - initial ck 436 - ck downtrending, 651 today - status post iv fluids - needs ck 1/31/22 with pcp   6. Transaminitis 2/2 rhabdomyolysis, covid 19, cirrhosis - alt/ast 41/49 on 6/15/21 - alt/ast 57/64 on admission - alt/ast 44/76 today - needs cmp 1/31/22 with pcp   7. Pancytopenia  - wbc/hgb/plt 2.98/11.1/102 on 6/15/21 - wbc/hgb/plt 3.85/13/119 on admission  - wbc/hgb/plt 2.35/11.1/97 today - needs cbc 1/31/22 with pcp   8. DM2 - hemoglobin a1c 6.8 - continue metformin, levemir  - may need further adjustment of medications as outpatient with pcp   9. Chronic back pain - continue gabapentin    10. Status post fall - ct head shows no acute intracranial abnormality - ct cervical spine shows no fracture - seen by PT   11. Lung nodule - cta chest shows 3 mm left upper lobe nodule - outpatient follow up with pcp   12. DVT - continue chronic anticoagulation with coumadin as outlined below - inr 2.1 on admission - inr 1.6 today - needs inr 1/31/22 with pcp   13. Obesity - bmi 36.07 - dietary and lifestyle modifications   14. Cirrhosis 2/2 nash - on rifaximin, spironolactone at time of admission  2/13/22  Readmission: 74 yr old M with PMH of HTN, T2DM, CKD, NASH cirrhosis, CVA, OSA (wears CPAP), obesity, and chronic back pain who presents for bloody stools.  Patient reports that he woke up this morning and had a bowel movement which was dark red blood mixed with his stool.  States that he had an additional episode around 8 AM that looks similar.  Reports some associated nausea and dry heaves with one episode of clear emesis.  Reports resolution of nausea or vomiting and denies abdominal pain.  Denies hematemesis, hemoptysis, or melena.  Denies NSAIDs use.  Denies fevers, chills, chest pain, shortness of breath, cough, sputum production, diarrhea, or urinary complaints.  Patient reports being diagnosed with a LLE DVT about 6 months ago and being started on Coumadin.  Reports that rash over left shin secondary to DVT and reports improvement in rash after being started on Coumadin. Patient also takes daily aspirin.