Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Hypertension, Hypoglycaemia, Insulin therapy, Lactic acidosis, Leukopenia
Clinical narrative: Admit date: 1/11/2024  Discharge date:  1/22/2024  Admitting Physician: MD   Attending Physician at the Time of Discharge:  MD  Primary Care Physician: DO Reason for Admission: 59-year-old married female with past medical history significant for uncontrolled type 2 diabetes mellitus, immunosuppression in the setting of rheumatoid arthritis on rituximab, adenocarcinoma of the left upper lobe of the lung status post lobectomy with no known recurrence and genitourinary syndrome status post menopause with some question of history of urinary tract infections versus other causes of bladder inflammation presented with worsening lower abdominal pain with lactic acidosis as well as worsening cough, fatigue and shortness of breath.  Patient also reportedly had a minor COVID-19 infection in December 2023.    Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  See hospital course by problem below.  In summary, there was initial concern for sepsis due to community-acquired right lower lobe pneumonia versus recurrent urinary tract infection.  Patient was started on empiric doxycycline and ceftriaxone and Urology was consulted.  Patient also had evidence of mild diabetic ketoacidosis and was started on an insulin drip with aggressive IV fluids and aggressive potassium replacement.  Patient was seen in consultation by Urology regarding acute on chronic severe bladder and urethral pain in the setting of sterile pyuria with multiple urine cultures on 01/11 and 1/12 negative.  Patient was taken to the OR by Urology who performed a cysto urethroscopy with bilateral retrograde pyelography and bladder biopsy and fulguration on 01/12.  Bladder biopsy showed evidence of denuded urothelium with acute and chronic inflammation with granulation tissue and no evidence of malignancy.  Notably patient developed rapidly progressing worse worsening respiratory failure on ceftriaxone and doxycycline.  Patient was seen by pulmonology and Infectious Diseases.  Antibiotics were broadened IV Zosyn with MRSA nares swab negative, however, with patient having no leukocytosis, leukopenia and markedly elevated CRP greater than 20 with CT chest on 1/15 showing diffuse bilateral airspace disease, I decided to retest patient for COVID-19 and it was positive.  Patient was started on Decadron and IV remdesivir and within 24 hours had marked improvement in respiratory status and was weaned off high-flow nasal cannula over several days..   Patient was eventually weaned off oxygen after completing 5 day IV remdesivir protocol while continuing Decadron 6 mg daily.  Patient also completed 7 days of IV Zosyn per pulmonology recommendations.  Patient had significant issues with hyperglycemia on steroids.  Collaborate with patient's outpatient endocrinologist regarding insulin regimen on discharge with only 3 additional days of Decadron remaining with plan for patient to follow up with endocrinology regarding ongoing diabetes management.  With respect to patient's suprapubic pain I am encouraging patient to discuss with primary care provider and Urology the possibility of interstitial cystitis and consideration for trial of amitriptyline to replace patient's sertraline if symptoms reoccur.  Hospital Course: 1. Acute hypoxic respiratory failure with increased oxygen requirement acutely from 1/14 to 1/16 - etiology of worsening not entirely clear, in my opinion COVID 19 pneumonia or other atypical process remains at least as high on my differential as a bacterial aspiration pneumonia with patient with no leukocytosis, lymphopenia, markedly elevated CRP, diffuse lung opacities and minimally elevated procalcition in setting of uncontrolled Type 2 DM which is a risk factor for COVID pneumonia, patient's underlying immunosuppression is a confounding factor as is prior + COVID 19 test and mild symptoms one month prior -significant clinical improvement since starting Decadron (started 1/16) -will complete IV Remdesivir 5 day protocol on 01/20 -will complete 7 days of IV Zosyn with last dose on 1/22 PM -completed 7 days of doxycycline  -ruled out for significant PE on 1/14, D-dimer now trending down -pBNP of 180 and relatively unremarkable Echo weighs against heart failure contributing -minimized IV Fluids when possible -diuresis with IV Lasix daily has been discontinued after volume status optimized with third-spacing early during hospitalization due to aggressive fluids in the setting of DKA  2. Sepsis, viral versus bacterial versus other: with intermittent fever; COVID 19 pneumonia +/- aspiration/hospital acquired PNA - CT Chest with diffuse opacities, CRP > 20 with lymphopenia in setting of immunosuppression, multiple urine cultures negative, blood cultures from 1/11 no growth final -resolved with completing concurrent treatment for COVID-19 pneumonia and the possibility of aspiration pneumonia as above  3. Hyperglycemia in setting of Type 2 DM, most recent HgbA1C 8.7, DKA: s/p insulin gtt, aggressive IVF, now resolved.  Then with worsening hyperglycemia again on Decadron and now with morning hypoglycemia -patient initially required up to 40 units of Lantus in the morning which was deescalated down to 20 after improvement in inflammatory lung condition;  -patient required up to 13 units of prandial Humalog which was then weaned down to 10 units before meals -patient was on a aggressive Humalog sliding scale q.a.c. and bedtime  - Holding home metformin, glipizide, Trulicity -discussed diabetic management on discharge with patient's outpatient endocrinologist with recommendations to stop glipizide and Trulicity and continue Lantus 16 units in the morning with Humalog 3 units before meals plus sliding scale with likely ability to stop prandial Humalog once Decadron stopped with patient to collaborate with endocrinologist post discharge, patient had continue home metformin  4. Acute on chronic anemia - normocytic, may have been hemo-concentrated on admission -Transfuse to keep Hgb > 7 or for signs of GI bleeding, hemoglobin improved to 7.9 -no evidence of iron-deficiency, B12 and folate within normal limits, reticulocyte count somewhat suppressed which can be related to sepsis  5 Abdominal pain on admission: etiology entirely unclear, acute and chronic inflammation on bladder lesion biopsy on 01/12, patient with prior treatment for recurrent urinary tract infections although many of the urinalysis were clean-catch with likely contaminated samples.  Query whether patient could just have pain related to postmenopausal issues and possibility of interstitial cystitis  - PRN analgesics  - bladder biopsy benign with acute and chronic inflammation -needs outpatient follow-up with Urology -could consider empiric trial of amitriptyline or neuropathic agent for interstitial cystitis -notably patient's urinary retention issues resolved prior to discharge and patient preferred to not continue tamsulosin or Motegrity  6. HTN - Holding home antihypertensives  -consider transition to oral antihypertensives as clinically indicated with last dose of IV Lasix today  7. RA - Holding home prednisone 2.5 mg daily held while on Decadron 6 mg daily (started 1/16 with planned through 1/25), plan to restart low-dose prednisone after completing 10 day Decadron protocol - Rituximab with last dose on 12/05, patient planning to work with Rheumatology did decrease her rituximab dosing this upcoming year  8. MDD - Zoloft, Wellbutrin  9. Hx adenocarcinoma of lung s/p left upper lobe lung resection with no known recurrence  10. Headache - PRN fioricet   11. Constipation - Bowel regimen  12. Thrombocytosis likely related to sepsis -peripheral smear unremarkable -patient on low-dose aspirin, follow up complete blood count after discharge  Discharged to Home Health Care