Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Hypernatraemia, Hypotension, Hypovolaemia, Hypoxia, Leukocytosis
Clinical narrative: PROGRESS NOTE 1/21/2022 ASSESSMENT/PLAN: This is a 66yo woman with hx of MS, stroke, right hemiparesis, neurogenic bladder with indwelling foley, sacral decubitus ulcer, diverting colostomy, CKD stage 4, seizure disorder, and iron deficiency anemia, admitted on 1/11 for dyspnea, FTH COVID+ (diag 12/20), anemia (Hgb 4.4), AKI, hypernatremia and fever (103F). Also FTH new LE DVT on 1/12. Hgb stable, starting heparin gtt w/o bolus on 1/13. O2 needs improving; ID consulted as well for guidance re ABX.  Course of zosyn for probable pneumonia, stopped on 1/20 for possible drug reaction, monitoring for resolution of erythema, borderline hyperkalemia on 1/20, improved on 1/21, Hgb < 8/0 though stable and no s/o bleeding.   Hypotension in the setting of GI bleed, hemorrhagic shock - resolved Severe Acute on chronic macrocytic anemia - resolved H/o chronic anemia, baseline Hgb ~ 9 (11/12), admitted 11/16 - 24 for decub ulcers/flap w/ plastics, prior to d/c at that time Hgb 7.6 (11/22) and required 1x pRBC peri-operatively. Hgb 4.4. on admission. Transfused w/ 3u pRBC, Hgb stable as of 1/12. Started on heparin gtt in the setting of DVT, subsequently noted to have Hgb drop from 9.5 to 6.7, blood in ostomy, and tachycardic with MAP < 65 requiring the addition of vasopressin to NE. Heparin gtt stopped and GI completed EGD and colonoscopy which showed no active signs of bleeding. With ongoing maroon colored stools. - GI consulted,appreciate recs - s/o on 1/18 - s/p EGD on 1/14 and colonoscopy 1/14: no acute findings - PPI BID for 30d, then to daily and outpatient f/u w/ GI - Hgb < 7.6 on 1/20-21, no evidence of bleeding, continue to monitor   Leukocytosis, Fever, Elevated lactate - resolved Possible severe sepsis - unknown source, possibly PNA vs. Sacral decubitus pressure ulcer  vs. Stress reaction 2/2 severe anemia Source not entirely clear, possibly skin. osteo, vs. UTI vs. PNA given hypoxia. However pt has been on broad spectrum abx (vanc/cefepime/flagyl) recently (11/22 - ?) due to sacral ulcers s/p plastics flap. BC/UC/sputum so far neg though has complex ID history (h.i enterococcus UTI, MRSA PNA, decub ulcers). MRI 1/12 w/o clear abscess/osteo; CT chest w/o contrast w/ possible PNA; MRSA screen on 1/12 wa neg which is reassuring. Pt does have DVT and new anemia, possibly lekocytosis, hypotension 2/2 that and not infectious. On Meropenem and vancomycin from 1/11 to 1/13. -ID consulted, appreciate recs - plan to continue Zosyn while inpatient, initial last date of antibiotic 1/24 (Augmentin PO) however developed possible drug reaction on 1/19 discussed w/ ID - stopped zosyn 1/19, monitor off abx   Erythema, likely drug reaction - resolving Developed RUE erythema on 1/19 w/ progressive involvement of LUE and upper torso. DVT US RUE neg, no trauma, soft. Cellulitis vs. Drug reaction; new eosinophilia from 1/17, started on zosyn on 1/14. Given progressive involvement of LUE, face, HDS, no fever, lactate wnl, only borderline leukocytosis suspect drug reaction, improving on 1/20 after zosyn stopped. - US UE: no DVT - stop zosyn, s/p 1x solumedrol 1/19 - monitor for new/developing sx of infection   Possible RLL PNA Pneumonia/Covid-19 positive, 1/11/22 Acute hypoxic respiratory failure Pleural effusions - 1/12, Candida in sputum, per ID probable colonization On admission w/ 4L O2, none at baseline, h/o MRSA PNA in Jan 2021; also admission in Oct 2021 for hypoxia - at that time thought to be aspiration pneumonitis. CT w/ contrast 1/13 w/ possible RLL PNA; procal elevated, fever on admission -- will treat. As far as covid, vaccinated x1 (May 2021), pos per report on 12/30, no sx, in ED on 1/4 for unrelated reason (GJ tube dislodgment) w/o resp distress or hypoxia. Unclear to what degree COVID is contributing but given new O2 needs, fever, recent diag will treat w/ std covid therapies. CT chest 1/12 shows small/moderate pleural effusions -- suspect 2/2 volume resus and needing D5W. Sputum culture yeast - likely contaminant. - ID consult and abx as above - O2 as needed - decadron: weaning off, last dose 1/21 - on PPI - VTE: new LE DVT, see below - maintain euvolemia   Acute L LE DVT Elevated d-dimer Found on US on 1/12, etiology unclear - in context of COVID however also has long-standing risk factors (bedbound at baseline). Heparin gtt stopped in the setting of acute GI bleed, IVC filter placed. - s/p IVC filter 1/15, needs to be removed or exchanged within 60 days.   Severe hypernatremia - Resolved Hyperkalemia - Resolved/stable CKD - stable NAGMA - resolved Baseline Cr ~ 1.8. On admission Cr 1.99 and Na 164. Suspect due to volume depletion and free water deficit. - stopped bicarb pm 1/18 - K 5.4 on 1/20, still good UOP              - changed diet to renal 1/20              - 1x 500cc NS              - K Q12H - monitor - BMP recheck within one week of d/c - outpatient f/u w/ nephrology   Sacral decubitus ulcer s/p myocutaneous flap on 11/2021 (w/ Dr.) S/p diverting colostomy (2021) Purulent discharge on 1/11, Culture ordered - none in EMR resulted as of 1/13 Chorinc stage IV ulcer now s/p myocutaneous flap w/ plastics (11/16-24), d/c on 4-6 wks of vanc/cefepime/flagyl), follows in a wound clinic in the system. Here there appears to be some dehiscence of the wound, EGS consulted, per EGS no indication for I&D, did express concern for exposed bone. MRI 1/13 (w/o contrast given AKI/CKD) w/o evidence of osteo or fluid collection.  Of note, prior to surgery diverting colostomy was done to facilitate wound healing. MRI 1/12 w/o osteo or abscess. - Surgery consulted, no immediate plans for I&D - Plastics seen on 1/3:              - no surgical intervention, wound cares: santyl to 4x4, pack into proximal open wound, cover with sacral mepilex, f/u outpatient w/ primary pastics surgeon asap - Wound culture showed VRE, ID aware    Neurogenic bladder with indwelling foley H/o enterococcus UTI UC showed NG. - Continue to monitor   Seizure disorder Continue Keppra.   T2DM Hgb 6.5 09/2021. Per EMR/med-rec PTA latnus 8u BID and SSI. - Continue Lantus 8 units BID, SSI   Nutrition H/o GJ tube malfuction TFs via GJ at baseline. GJ tube has been dislodged several times in past, most recently replaced on1/4 at.   - s/p gastrojejunostomy tube replacement 1/15