Age: 55.0
Sex: F
Vaccine: COVID19
Symptoms: Hypomagnesaemia, Hypoxia, Intensive care, Klebsiella urinary tract infection, Pathogen resistance
Clinical narrative: Patient is a 56 y.o. female with a history of HTN, morbid obesity, DM2 c/b neuropathy, CKD, GERD, and adenocarcinoma of cecum who initially presented from facility to Hospital with worsening SOB and hypoxia in the setting of recently diagnosed COVID pneumonia. Found to be in acute hypoxic respiratory failure ultimately requiring intubation. Transferred to hospital 2/17/2023 for further management. Course complicated by MRSA pneumonia and recurrent R pleural effusion (suspected hepatic hydrothorax). Extubated 2/20/23 and urgent care consulted to assume care out of ICU on 2/21/23. Remarkable recovery and no further re-accumulation of pleural effusion with stable dose of diuretics. Discharged to SNF on room air.   1. Acute hypoxic respiratory failure: Baseline no O2 requirement. Initially due to COVID and superimposed MRSA pneumonia with right pleural effusion, ARDS. Subsequent recurrent right pleural effusion, atelectasis, shunting contributed to recurrent respiratory failure. Intubated 2/17/23, extubated 2/20/23. Worsening oxygenation 2/25/23 with rapidly re-accumulating pleural effusion as below. Resolved with repeat chest tube for effusion drainage. Diuresis as able. Room air on day of discharge. 2. Recurrent R sided pleural effusion: Hepatic hydrothorax. S/p thora 2/17/23 with transudative effusion. S/p R pigtail chest tube, removed 2/20/23. Worsening effusion again 2/25/23. S/p repeat thoracentesis with IR with 1.2L off, transudate again. Recurrent effusion noted 2/26/23 requiring chest tube placement. CT removed 3/5/23. VIR followed, poor candidate for TIPS. Hepatology following, considered OLT but also poor candidate with obesity. Started Bumex and Aldactone 3/6/23. Repeat CXR 3/9/2023 prior to discharge with minimal effusion. 3. MRSA pneumonia: s/p bronch 2/17/23 with BAL cx positive for MRSA. Completed Vancomycin course 2/24/23. 4. COVID pneumonia: dx 2/15/23 at hospital, vaccinated with primary series and booster per patient. Positive BAL 2/19/23. Remdesivir course and Decadron completed on 2/27/23. Out of isolation. 5. AKI on CKD3: likely prerenal, admit Cr 2 with baseline in 2018 of 1.5. Renal US 2/18/23 unremarkable. Appears at baseline 3/5/23. Monitor with resuming diuretics.  6. Decompensated liver cirrhosis, new diagnosis: Newly diagnosed based on CT A/P at hospital, liver with cirrhotic morphology and small ascites. Potentially NASH. AFP 1.7 on 2/17. Hepatology followed, recommended outpatient follow up for EGD and screenings, scheduled 3/22/23. Diuretics as discussed above. 7. ESBL Klebsiella UTI: UA infectious and cx 2/17/23 grew ESBL. Completed course of Ertapenem 2/21/23.  8. Sepsis: Multifactorial due to the above. Abx as above. Resolved.   9. Hypomagnesemia: Replete PRN. Scheduled daily repletion since continually low.  10. Anemia, thrombocytopenia: likely in the setting of acute illness. Hgb ~10 and plt >100, monitored and both Hb/plts remained stable.  11. NIDDM2: A1c 6.3. Held home meds. Started on basal/bolus insulin. Monitored and titrated for inpatient goal.  12. Uncontrolled HTN: Per hx, BP intermittently uncontrolled inpatient. Some home meds initially held. Amlodipine / carvedilol adjusted. Diuretics as above. 13. Neuropathy: Per hx. Continued home Lyrica renally dosed. 14. Severe obesity: Body mass index is 65+. Recommend outpatient bariatric follow up.