Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Hypophagia, Hypotension, Hypovolaemia, Lactic acidosis, Left ventricular dysfunction
Clinical narrative: Patient is a 68 y.o. female with a history of HFpEF, Pulmonary HTN, COPD (1L), DVT (Eliquis), CKD III, IDDM2, Chronic Pain, Psoriatic Arthritis, OSA, Restless Leg Syndrome, and Obesity. She was recently admitted to hospital 9/1-9/4/23 for atypical chest pain and nausea/vomiting. She presented to hospital 9/22/2023 for 1 week of poor oral intake and 1 day of hypoglycemia, encephalopathy, and hypotension. Found to have COVID, symptoms improved with steroids. Course prolonged due to disposition.   1. COVID-19: Vaccinated. Symptoms started ~9/15/23 (7 days prior to admission). SARS-CoV-2 positive on 9/23/23. CXR 9/22/23: mild pulmonary congestion. As needed IV lasix for "dry lung" strategy. Required O2 on admit, since weaned off. Stopped decadron ordered as no benefit once patient is off O2.  2. Acute on Chronic Hypoxic Respiratory Failure: history of COPD and pHTN. Prior to admission was supposed to be on 1L oxygen around the clock at home but only used as needed. Required 2L via nasal canula on admit. Weaned to RA by 9/24/23. Discharged on room air. 3. Abnormal UA: UA in ED with small leuk est, 32 WBC, rare bacteria. Patient reported decrease in urine output. ED started IV ceftriaxone, due to lack of symptoms held further doses. Blood cultures 9/22/23: negative. Urine culture 9/23/23: negative.  4. Anorexia: 1 week poor oral intake, suspect due to COVID. RD followed. 5. AKI: Baseline SCr ~1.1, however SCr 1.6 in ED. Likely prerenal due to anorexia. Resolved with IVF. 6. Hypotension: BP 52/36 upon presentation. Improved with 2L of NS. Suspected due to above. Resolved.  7. Resolved Lactic Acidosis: Lactate of 3.4 in ED, resolved to 1.4 after 2L IVF.  8. Chronic Diastolic Heart Failure, Pulmonary Hypertension: TTE 9/1/23: LVEF 69%, grade 1 diastolic dysfunction, slightly reduced RV systolic function, mild MS, mod TR, RVSP 87. Dry weight ~184lbs, 186lbs in ED. Appeared hypovolemic in ED and on follow up. Home torsemide held, resumed 9/24/23. 9. Elevated Troponin: In ED: Trop T 63-- >52, NT-Pro BNP 7.1k, without chest pain. Suspect demand ischemia in setting of above. Reassuringly patient was evaluated by Cardiology 9/2/23 for atypical chest pain. Echo as above without wall motion abnormalities. No further workup.   10. Chronic Bilateral Foot Wounds: Followed by Dr. (Podiatry) s/p recent surgical intervention. Monitored.  11. Chronic Anemia: baseline Hgb ~9-10. Hgb of 10.5 (MCV 75) in ED. Continued home iron.  12. Gallstones: Followed by Dr. (General Surgery). HIDA 9/3/23: normal EF, no cholecystitis.  13. Gastritis: EGD 9/3/23 showed minimal gastritis and endoscopic barrett's.  14. IDDM2: Hemoglobin A1c 7% (8/2023). Held home Trulicity while inpatient. SSI. Titrate as needed. 15. DVT: by history. Continued home Eliquis 5mg BID.  16. Chronic Pain Syndrome: with opiate dependence by history. Reviewed NARx report and patient is getting consistent fills of Lyrica 150mg (#90, 30d supply) with last fill 7/2023 + Oxycodone-Acetaminophen 10-325mg (#120, 30d supply) with last fill 8/2023. Continued oxycodone. Patient on greater than recommended dose at home, dose reduced Lyrica based on renal function.  17. Class II Obesity: BMI 39. Recommended lifestyle changes.