Age: 71.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Lactic acidosis, Lung infiltration, Lymphopenia, Major depression, Pulmonary embolism
Clinical narrative: Provider Summary "71 year old male living alone with past medical history significant for obesity, Type 2 diabetes mellitus, longstanding nicotine dependence, hypothyroidism following iodine therapy, hearing loss, alcoholism in remission, prostate cancer status post prostatectomy (recently found to have elevated PSA again) and poor compliance presented with difficulty urinating and having bowel movements, generalized weakness and a significant yeast infection in his groin and perineum. He was noted to have fevers, lymphopenia and lactic acidosis concerning for sepsis.    He was also found to be + for COVID 19.    Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)    Sepsis with lactic acidosis, lymphopenia and fevers with possible fungal/bacterial cellulitis Admitting provider presumed sepsis due to fungal cellulitis with possible superimposed bacterial infection.   Patient was cultured up and started on IV Vancomycin, Zosyn and Fluconazole.  He was continued on IV Vancomycin for possible cellulitis. He was later thought to have a UTI with an abnormal UA and was started on IV Ceftriaxone.   Urine culture grew multiple different strains of bacteria with low CFU and without significant urinary symptoms other than retention, UTI was not felt to not be a valid diagnosis.   Cellulitis was improving and patient was switched to Cephalexin to complete a five day course of treatment.  Both Cephalexin and Fluconazole were discontinued with resolution of candidal infection and cellulitis.    Acute respiratory failure with hypoxia in setting of COVID 19 pneumonia, viral sepsis and pulmonary embolism Patient developed an oxygen requirement escalating to need for 5 liters by nasal cannula with patient on no supplemental oxygen at home.  Initial CXR was unremarkable.  Checked D-dimer which was greater than 3000.  With suspicion for pulmonary embolism, obtained CT Angio of Chest which showed pulmonary emboli in the segmental branches of the pulmonary arteries in the RUL, RML, RLL and lingula. It also showed peripheral infiltrated suspicious for COVID 19 pneumonia.  Patient was started on Decadron 6 mg daily as well as IV Heparin for pulmonary emboli.   He was given scheduled Albuterol, symptom and supportive care with aggressive pulmonary toilet.  He was encouraged to use prone positioning.  Over time, patient's respiratory status improved remarkably and he was weaned off supplemental oxygen.  His IV Heparin was transitioned to Eliquis.  Patient had significant hyperglycemia on Decadron and with resolution of hypoxia and most respiratory symptoms, Decadron was stopped after 7 days.   Type 2 diabetes with hyperglycemia in setting of infection and steroid use -  Patient with HgbA1C of 7.4 prior to admission on Metformin only.  Patient developed significant hyperglycemia in the 300s on decadron.  He received aggressive Insulin titration and eventually was on Lantus 40 units at night with Humalog prandial 10 units before meals with aggressive sliding scale.  Patient was very resistant to considering Insulin at home.  Decadron was discontinued and patient was transitioned off Insulin back on to home Metformin with addition of Glipizide.     Depression, hoarding behavior and lack of motivation Patient was willing to trial Bupropion targeting his depression.  The hope is that it would have a secondary benefit of promoting smoking cessation   Nicotine dependence - 3 packs of small cigars daily Patient was counseled regarding benefits of smoking cessation but was not interested   Generalized weakness with debility PT and OT were consulted and recommended home care with therapies on discharge   Gross hematuria with anticoagulation after temporary Foley catheter placement Improved with removal of catheter Recommend follow-up this issue with Urology in addition to the elevated PSA with history of prostate cancer status post remote prostatectomy   Abnormal rectosigmoid colon thickening on CT - recommend referral to GI for colonoscopy as an outpatient   Issues Requiring Follow Up: (Who, what, when, and how communicated?)  Follow-up pulmonary embolism and resolution of COVID 19 pneumonia with PCP, recommend three to six months of anticoagulation with follow-up with hematology; follow-up with Urology for elevated PSA with history of prostate cancer and gross hematuria; follow-up with GI for abnormal recto-sigmoid wall thickening"