Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Influenza virus test negative, Macrocytosis, Metabolic function test abnormal, Nephrolithiasis, Nitrite urine present
Clinical narrative: Patient is a 71-year-old obese male, with known history of hypertension, CAD, status post myocardial infarction, a recent bout of COVID-19 infection, who presents essentially 13 days post discharge after he was admitted because of signs and symptoms of acute respiratory failure related to COVID-19 infection.  The patient was presumably started back up on nifedipine for blood pressure control.  Per family member, Patient has had in the past problems with calcium channel blockers while they may come retain more fluid.  The patient reported return and worsening of difficulty in breathing, reason why he decided to come back into the hospital for evaluation.   Workup in the emergency room does find the patient moderately hypertensive with a blood pressure 183/94, tachypneic, respiratory rate 36, otherwise afebrile.  Saturating down to 81% on room air.  ER stay was complicated by requiring BiPAP.  He has now been successfully weaned off.  Further workup in the emergency room does include a CMP that shows a BUN and creatinine are 37 and 1.7 respectively with a glucose of 116.  Albumin 2.2.  Potassium 5.7 from presumably a slightly hemolyzed sample.  BUN and creatinine ratio is 22. Troponin is 9.1.  CK and CK-MB 60 and less than 2.5.  LDH 268.  Ferritin 776.1.  D-dimer is 1234.  CBC with differential shows no concerns for infection.  COVID-19 testing still positive.  Influenza panel respiratory syncytial virus negative.  Duplex of the left upper extremity negative for DVTs.  One view of the chest ordered and pending.   Because of the above findings, the patient did go on to receive Lasix, Solu-Medrol, as well as tramadol and gabapentin and Hospital Medicine was then called to admit the patient to the hospital for further monitoring, workup, and treatment."   Patient was admitted to medical telemetry.  He was notably anasarcus with fluid retention from toes up to abdomen with notable scrotal swelling.  Cardiology, Nephrology consulted.  Aggressive diuresis initiated.  The patient initially with good diuresis and then plateau.  He has been transitioned to Lasix 40 mg p.o. On discharge.  Continued daily weights with monitoring of intake and output with fluid restriction is recommended.  Cardiology was able to adjust medications given elevated blood pressures.  He will need follow up with Dr.    Findings for COVID-19 pneumonia on admission was ruled out.  It is noted the patient does have historical COVID-19 pneumonia dating back to December 9, 2021. Despite no leukocytosis nor growth on blood cultures, urinalysis was abnormal with nitrates and leukocyte esterase.  Repeat UA confirmed similar.  Cultures obtained.  He had two culture growths of E. coli.  Renal ultrasound revealed a persistent right renal stone which is the likely etiology in combination with self catheterization due to neurogenic bladder due to history of back injury, status post surgical intervention.  PSA was not elevated. Patient was treated with Cipro-which was renal dosed..  This should be continued for a full 14 days.  Surveillance for UTIs is recommended noting the patient's kidney stone is nonobstructing and will not likely resolved.  Additionally given his neurogenic bladder he is at risk for UTIs.  He will need regular follow-up with Dr. MD    It is noted that he was given Ultram which did not help his pain.  He was given Remeron which did not help asleep.  Both of these medications did make him groggy and alter his mentation with episode of him hallucinating that his roommates diagnosis for his.  Additionally he was given Flexeril and remained very groggy for at least 6 hr after dosing.  He had been on Ultram outpatient.  He was also on Benadryl.  These were both stopped due to the potential for urinary retention.  Additionally Benadryl has anticholinergic affects which could be negatively affecting his mentation.   Hyper start an was held due to potassium sparing affects and presentation with hyperkalemia.  This was not resumed.   AKI on admission in setting of chronic kidney disease stage IIIB with AKI following CTA 12/28/21 and with secondary hyperparathyroidism due to Renal osteodystrophy.  He was started on calcitriol 3 times weekly-Monday, Wednesday and Friday. Hypercalcemia treated with calcium carbonate/Tums.  With chronic kidney disease Rolaids should be avoided due to aluminum content.  He is continued thusly on times daily.  He is encouraged to eat a low-sodium diet of 2 g low-potassium diet of 2 g as well as maintain a 2 L fluid restriction.  Apresoline was increased from 50-75 mg t.i.d. Uric acid elevated at 8.1 -  He will require follow-up with nephrology.   Macrocytosis appreciated with low B12.  Repletion with cyanocobalamin started and is recommended lifelong.  Folate was low normal.  Folate repletion also started given synergistic action.   Patient was able to taper oxygen to 4 L via nasal cannula from Bipap for treatment of presenting hypoxia measured at 81% on Room Air.  At baseline he reports no home supplemental oxygen use. On discharge he has new diagnosis of chronic respiratory failure with hypoxia.   CT- chest 12/28 did reveal bilateral pulmonary effusions.  These could be re-evaluated in the future if anasarca recurs.  Given his frail nature with severe deconditioning and multiple allergies. Thoracentesis was not considered.  In the future, with continued diuresis if these have not resolved, He may benefit from thoracentesis  He participated in PT and OT with acknowledgement that at home he generally furniture walks and is severely deconditioned.  He is discharging to skilled nursing facility for continued multi disciplinary therapy.  He will need close specialist follow-up and urine surveillance given recurrence of UTI.