Age: 89.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Acute myocardial infarction, Acute pulmonary oedema, Acute respiratory failure, Agitation
Clinical narrative: 90 y.o. male with a PMH of Afib (on coumadin), HFpEF, CAD, CKD stage 4, non-hodgkin's lymphoma, COPD (2L NC), T2DM, HLD, hypothyroidism, SSS s/p dual chamber pacemaker. Presented 12/13/22 with generalized weakness. Found to be COVID + and in Afib w/ RVR. Hospitalization complicated by aspiration event with respiratory failure requiring ICU care 12/14-12/15 with HHFNC, development of acute delirium 12/15, and pre renal AKI 12/16. Course further complicated by episode of rectal bleeding overnight 12/20. GI consulted, bleeding scan negative. Course also complicated by persistent Afib RVR and intermittent agitation, also hyperglycemia. Discharged home with HHC on 12/23 with plans for close follow up with PCP.    Comments/Problems to be Addressed After Discharge - Repeat BMP outpatient for AKI resolution, resume torsemide outpatient as able - repeat CBC within one week for evaluation of anemia - risk benefit discussion regarding Warfarin and Plavix with PCP - adjust insulin and diabetic regimen PRN   Discharge Diagnosis and Associated Hospital Course   Rectal Bleeding, Resolved  Acute Blood Loss Anemia, Resolved - Concern for lower GIB with bright red blood during hospitalization in setting of anticoagulation  - required 1unit pRBC overnight 12/20 - bleeding scan negative 12/21 - GI followed. Will hold warfarin and plavix on discharge. Risk benefit discussed with family and patient's PCP.     NIDDM2 Hyperglycemia - On home glipizide 5 mg BID. Etiology of hyperglycemia unclear, decadron could be contributing.  - A1c 7.3. Hyperglycemic into the 300-400's.  - Continue 10U humalog TID with meals and sensitive sliding scale. Will continue to monitor and adjust as needed. Consider addition of basal insulin on 12/23  - Discharged with sliding scale lispro. Plan for close follow up with PCP outpatient. Ok to resume Glipizide on discharge   AKI, improving Baseline Cr ~1.8 to 2. Likely pre-renal in setting of decreased PO intake with restraint use.  - Foley removed 12/17 and trial voids appropriate to date  - S/p LR 100cc/hr for 10 hours 12/21.  - Avoid nephrotoxic agents. Renally dosed Gabapentin to 300mg nightly. Encourage PO intake. Repeat BMP   Aspiration Event Occurred in ED on admit with acute hypoxia. Improved with HHFNC in ICU.  - again with concern of choking on pill 12/21. Repeat CXR improved - Speech followed. Recommended chopped and thick liquid. Plan for speech therapy with HHC.  Acute on Chronic Hypercarbic Respiratory Failure, Resolved  - Likely secondary to aspiration event, flash pulmonary edema, subsequent pneumonitis during stay in ED. Less likely secondary to COVID-19 infection, acute HF exacerbation. With chronic COPD on home 2 L, known chronic bilateral pleural effusions.  - CXR on admission with bilateral R>L pleural effusions, mild pulmonary vascular congestion.  - S/p IV lasix with improvement in respiratory status - Required HHFNC in ICU, weaned to home 2L NC. SpO2 goal 88-92%.    Concern for UTI, Resolved  - 12/15 PM: patient became acutely delirious, workup for delirium including UA and Urine Cx obtained - UA with large blood, large leukocyte esterase, 24 WBC, 34 RBC, rare bacteria - Urine Cx with coagulase negative staph.  - S/p 5 day course rocephin completed.   Acute Encephalopathy, Improved  - Etiology upon initial presentation likely multifactorial including acute respiratory failure. 12/15/22 event of acute agitation likely secondary to underlying cognitive impairment, sundowning event, possible dexamethasone induced.  - UA obtained at time concerning for possible UTI with empiric treatment initiated although unable to determine if symptomatic - Decadron held in setting of acute delirium - intermittently required PRN agitation medication throughout hospitalization. Not continued on discharge   Afib w/ RVR, improved - Likely exacerbated in setting of COVID infection, respiratory failure. Family reports unable to tolerate rate control with BB in the past.  - Started on cardizem gtt in ED, switched to IV Lopressor with subsequent transition to PO cardizem 240 mg daily 12/15/22.  - Holding Warfarin due to GI bleed. Cardizem prescribed on discharge.    COVID 19 infection - First developed symptoms 12/12, tested positive 12/13 - Patient vaccinated x3 - ID eConsulted, will hold off on Paxlovid, initially started on Decadron 10 day course - Hold Decadron in setting of acute delirium 12/15, supportive care. Isolation discontinued 12/23   Bilateral pleural effusion Malignant pleural effusion  - Etiology likely malignant given history of malignant effusions with marginal zone B-ell lymphoma vs heart failure.  - Following discussion with patient, family, and PCP did not pursue thoracentesis.     Type II NSTEMI  - Secondary to ischemic demand in setting of AF with RVR and aspiration event. With known prior CAD history. Without symptoms consistent with ACS to date.  - Admission troponin 146 > 136, below prior baseline  - Admission EKG with ST segment abnormalities V2, V3, V5, V6. ST segments appear stable from prior baseline EKG, with new RVR on admission EKG.   Chronic HFpEF - Patient reported to follow with Dr.  - TTE 02/2021 with EF51%; Repeat Echo with EF50%, borderline pulmonary hypertension - Home regimen: Torsemide 40mg daily - Given 80 mg IV lasix in ED, responded well. Started on 40mg Lasix IV q8 12/14 with plan to transition to home torsemide 12/17/22.  - Diuretics held in setting of AKI 12/17. Resume as able outpatient   COPD without exacerbation  - Per hx on 2L NC at home  - Low concern for acute exacerbation, continued home regimen   Marginal zone B-cell lymphoma (HCC)  - Malignant pleural effusion 12/28/20221 consistent with marginal zone lymphoma. Appears rituximab was held during omicron surge. Per family, patient not pursuing treatment, but would consider it pending need for recurrent thoracentesis - Management per above   Sick Sinus Syndrome - s/p dual chamber pacemaker   CAD - Follows with Dr., history of MI. Multiple PCI's, last cath 2019: mild CAD with well-preserved LV function. PCI to diagonal. CABG multiple years ago.  - Last visit with Dr. in 09/2021, plavix was decreased to three times/ week due to bruising. Instructed to follow up in two years. No end date for plavix.  - Continued home statin. Holding plavix and warfarin in setting of GIB. Further discussions with family on risks/ benefits of continuing anticoagulation in setting of high stroke and high bleeding risk.    HLD - Continued home statin   Hypothyroidism - Continued home synthroid   GERD - Continued home protonix   Insomnia  - Continued home remeron