Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Pulmonary embolism, Renal impairment, Resuscitation, Rib fracture, Right ventricular dysfunction
Clinical narrative: Discharge Provider: DO Primary Care Provider: DO Admission Date: 2/20/2023 Discharge Date: Mar 18, 2023  PRESENTING PROBLEM: Cardiac arrest   HOSPITAL COURSE: Patient is a 68 y.o. female with pmhx of T2DM, HTN, HLD, CAD (hx stent 2000), hx R PCA stroke, bil carotid stenosis, who presented after cardiac arrest. Last known well was 2130 on 2/20. She was found at approximately 1200 on 2/21 on the bedroom floor unresponsive. CPR started by family and continued by EMS. ROSC was achieved and the patient was transported to ED.  The patient's had recently been on Bactrim for lower extremity cellulitis for approximately a week and had diarrhea.  She also has a history of worsening kidney function.  Patient was intubated for airway protection.  She was found to have an initial lactic of 5.2, potassium 6.9, and VBG showed pH of 7.07, pCO2 of 45.9, and PO2 of 59.2.  The patient was found to be incidental COVID positive.  CTA thorax at outlying facility showed subsegmental PE in the left lower lobe but possible artifact, small pleural effusion bilaterally, atelectasis, and multiple bilateral rib fractures, likely secondary to CPR.  CT also showed infrarenal AAA measuring 5.2 cm.  Patient was transferred to ICU.   Hyperkalemia (possibly from bactrim) was treated with calcium, insulin, and Lasix.  Patient continued to be hyperkalemic and was treated with an additional dose of calcium, insulin, and Lokelma.  Hyperkalemia and metabolic acidosis were refractory to medical treatment. Dialysis catheter inserted by ICU and nephrology was consulted for CRRT which was initiated 2/21.   Echo 2/20 showed decreased EF at 24%, severe tricuspid regurg, and moderately decreased RV function.  Cardiology consulted.  The patient had minimal urine output and gross hematuria.  Heparin was held and Urology was consulted. Foley irrigation improved urine output and dispelled clots. UA without evidence of infection. Cytology without evidence of malignancy. Urology recommended outpatient follow up for cystoscopy.   MRSA swab was negative.  Sputum culture and peripheral blood cultures negative. Patient completed 5 days prophylactic Rocephin in setting of arrest and intubation. Pressors and sedation weaned off. MRI brain for neuro prognostication and possible deficits noted no anoxic brain injury and not acute infarct, only prior infarct.  Patient was extubated to BiPAP on 02/23.  Repeat echo showed ejection fraction of 46%.  CRRT stopped 2/24 in the evening. Nutrition consulted and placed corpak 2/24. Tube feeds started for nutrition.    ENT consulted 2/28 for epistaxis in setting of anticoagulation. Placed dissolvable nasal packing. With resolution of epistaxis heparin drip resumed and later transitioned to eliquis in setting of afib and possible PE.   Nephrology continued to follow with iHD initiated 2/25. And with improvement of renal function and good output HD stopped with last run 3/3. Vas-Cath removed 3/10. Renal function continued to improve and likely ischemic ATN resolved. Recommend repeat BMP in 1 week to monitor for ongoing improvement and recheck potassium.     Cardiology followed patient. Changed from atenolol to metoprolol in setting of new onset afib during admission. Plan to follow up outpatient.   Mental status continued to improve. SLP evaluated patient. VFSS performed 3/8 initially recommended pureed solids and thin liquids with medcations whole in pudding. With ongoing SLP her diet was advanced to general solids and thin liquids with meds whole in puree at time of discharge. Patient accidentally removed corpak 3/13 but was able to increase PO intake and passed calorie counts. She was fully oriented at time of discharge.   DGMS was consulted and recommended holding of orals with basal bolus insulin at SAR.    PT and OT evaluation recommended skilled nursing facility and discharged to SAR in stable condition.