Age: 74.0
Sex: F
Vaccine: COVID19-2
Symptoms: Malnutrition, Mental status changes, Metabolic acidosis, Pelvic fracture, Persistent complex bereavement disorder
Clinical narrative: Patient is a 74 y.o. female with a past medical history of remote gastric bypass, CAD, Raynaud's disease on plavix, recent admission for GI bleed and DVT (11/30-12/2) s/p IVC filter, found COVID positive (11/30), who presented via EMS on 12/4/2022 after being found down at home. She presented with altered mental status, hypoglycemia (initial glucose 22), rhabdomyolysis, and acute hypoxemic respiratory failure secondary to COVID-19. She was transferred to MICU for closer monitoring. She acutely decompensated 12/6 with concern for RV dysfunction, and acute cardiogenic shock. She required multiple pressors and placement of NRB. On discussion with patient's daughter and son, the decision was made to transition Patient expressly to comfort measures. She was transitioned to a DNRCC and died on 12/6/2022 at 2203 surrounded by her family   Discharge Diagnoses:   Acute Cardiogenic Shock   Acute Hypoxemic Respiratory Failure Secondary to atelectasis, COVID  -CXR with focal infiltrate of right lower lobe -No obvious aspiration concerns per SLP -F/U Echo w/ bubble study given CTA 12/01 with concerns for RHS/PHTN -BNP pending  -CAP coverage (Azithro and Rocephin) given elevated procal  -F/U sputum culture  -Continues on LFNC for O2 goal 92%+ -Covid tx as below    COVID-19 infection Tested positive 11/30, isolation to end 12/6 -Decadron 6mg (12/05-12/15) -Procal/Ferritin/Inflammatory markers pending    Acute Encephalopathy Infectious/metabolic  -Glucose, TSH, LFTs abnormal as below -Ammonia WNL -B12/Folate pending -Thiamine given hx of bypass -CTH nonacute, chronic infarcts -CT neck w/ multilevel degenerative changes (C3-C7) w/o evidence of acute fx or subluxation  Hypoglycemia Likely d/t poor PO intake in setting of acute illness -A1c 6.0 -On D10 infusion -Fingerstick glucoses inaccurately low due to raynauds -Wean and stop once tube feeding started -Glucose checks q1 hrs until stabilized   Hyperkalemia Unclear eitology -Potassium 5.5, EKG pending, no obvious changes rhythmn on telemetry -Monitor, consider lokelma if uptrending    Abnormal Thyroid Labs  Hypothermia No previous diagnosis of hypothyroidism -TSH 15.10, FT4 0.6 (12/5/22) -IV synthroid x1  -Starting levothyroxine 50mcg/day with repeat labs as outpatient in 4-6 weeks   Transaminitis  Acute Liver Injury Unclear etiology -Initial labs: ALP 353/ Bili 1.5/ AST 360/ ALT 161 INR 1.7 -Vitamin K+  -RUQ US pending    Metabolic Acidosis Lactic Acidosis Likely d/t dehydration, slow resolution due to transaminitis  -ABG 7.32/42/21.6 -3.4 on admit, up-trending to 4.0 12/6 -Trend for resolution with IVF  -Given 1 amp bicarb   Malnutrition Present on admission BMI 14.27 -Possible risk for refeeding syndrome, empiric thiamine started 12/6 -Dietician consulted -Trend electrolytes (Phos WNL) -Follow up extended vitamins given gastric bypass hx -Gen Surg consulted - Bariatric team to see given need for supplemental feeding and inability to use NG given her abnormal anatomy   Complicated Grief / Adjustment disorder -Patient recently loss husband ~2 months ago -BH consulted,signed off 12/6 -Re-consult when patient's mental status improved, concern for severe depression per family's report.    Pelvic Fx - Per CT pelvis 12/1/2, CT 12/5. Known fx of left greater trochanter, right superior and inferior pubic rami  -Ortho consulted - Conservative mgmt, WBAT -Avoid abduction of left hip -Follow up with Dr. in 4 weeks    Rhabdomyolysis, resolved  Likely d/t dehydration, COVID-19, found down at home -CPK 1369 on admit, downtrending to 682 12/6 -No need for further monitoring    Acute Kidney Injury on CKD stage III, resolved In setting of rhabdo, dehydration -Increased from 0.91-1.32 -Now improved to around baseline