Age: 82.0
Sex: M
Vaccine: COVID19
Symptoms: Gastrointestinal haemorrhage, Haemoglobin decreased, Hypotension, International normalised ratio increased, Intestinal dilatation
Clinical narrative: Pfizer Dose 1 2/9/21 (el3302) Pfizer Dose 2 3/3/21 (EN6199) Pfizer Dose 3 12/8/21 (FH8027) COVID Positive 12/14/21  12/19/21: Patient is an 82 year old with a past medical history of COPD, CKD stage 3B, CAD, chronic CHF, HTN, HLD, AFib with pacemaker, and BPH who presented to the ED with shortness of breath and sore throat.  The sore throat started today and his shortness of breath he has had for about 1 week.  He also endorses a non-productive cough. Denies fever, chest pain, diarrhea, loss of sense of taste or smell.  He has a decreased appetite and says he has been trying to drink PO fluids but his throat hurts too much. He was recently evaluated in the ED on 12/14 when he presented with shortness of breath for 3-4 days.  He was discharged with a diagnoses of COPD exacerbation.  He was given prescriptions for Prednisone 50mg PO daily for 5 days which he completed today and Levaquin 750mg PO daily for 7 days. He has 3 tablets remaining.  During that hospital visit he was found to have a supratherapeutic INR and was told to contact the Coumadin clinic. He states that they told him to continue taking his Coumadin.  Denies active bleeding. During that ED visit he was also found to be COVID-19 positive.  He received 2 doses of the Pfizer vaccine and the Pfizer booster.   In the ED: VSS.  Labs remarkable for glc 112, cr 2.48, ca 10.3, ProBNP 2418, WBC 12.98, INR > 9.  CXR no acute findings.  U/A demonstrated moderate blood and leuk esterase.  He was given one duo-neb treatment, 1g ceftriaxone, methylprednisolone OT, 500mL NS bolus x2, and vitamin K.  1/2/22: Patient initially saturating well on room air. Treated with Mucinex and respiratory therapy.  Respiratory status was relatively stable throughout hospital course and did not require COVID protocol treatment.   Nephrology was consulted on 12/22 for AKI they believed to be due to cardiorenal syndrome.  Bladder scan showed urinary retention and Foley catheter was placed.  Was attempted to be removed on 12/22, urinary retention continued and was placed back in.  Blood pressure was closely monitored in fluids were started.  Kidney function was closely monitored throughout hospital course. Nephrology continued to follow along with patient's kidney function.  He was continued on Bumex drip, D5 at low rate, and cinacalcet.  Nephrology had continued discussion with patient about dismal kidney function and concern for dialysis or CRRT.  Patient was interested in neither.  His Bumex drip was stopped late in hospitalization.  Nephrology subsequently signed off.   Daily INR checks were in place.  Warfarin was given only 2X in 1 mg doses when INR return to therapeutic range, but patient was very responsive to this and cause it to increase again.  Pharmacy recommend consideration of alternate form of anticoagulation once back in the outpatient setting.  Daily INR checks were continued throughout admission and INR was noted to rise despite warfarin being held.  No anticoagulation was restarted on discharge secondary to patient's desire to stop workup of GI bleed and no definitive treatment being made.   On 12/24, patient developed bradycardia, and so an inquiry was run on patient's device.  It was found that on 12/19 he had an episode of VFib that resulted in an ICD shock. Patient was unaware of this.  It was then found that patient was in ventricular bigeminy and amiodarone was started in an attempt to suppress his ventricular ectopy. This was effective and bigeminy was improved, amiodarone was switched to oral and decreased throughout hospital course.  Cardiology consult was recommended by EP. Curbside consult on 12/27 was done and it was recommended to restart patient on metoprolol 12.5 b.i.d. for AFib. Official consult was not warranted.  Metoprolol was intermittently discontinued due to low blood pressures but ultimately restarted.  Per EP recommendations patient was continued on amiodarone 400 mg daily as an outpatient with close follow-up scheduled.   Covid protocols discontinued on 12/25 due to patient being outside the 10 day window since testing positive. Continued to remain stable in terms of his respiratory status.   On 12/26, a rapid response was called on patient due to shortness of breath after getting up to use the restroom. He was started on supplemental O2.  Abdominal distention was noted on physical exam, blood pressure 95/70, heart rate in the 70s.  Telemetry reported paced rhythm, no redness.  Chest x-ray showed fluid in the right lower lung, otherwise no acute changes.  Respiratory therapy placed BiPAP on patient.  Lasix and Solu-Medrol given at that time.  Breathing improved.  KUB was ordered which showed possible volvulus with gaseous distension.  CT the abdomen was ordered and showed gaseous distention of the cecum and transverse colon but no obvious volvulus or obstruction. Surgery was not indicated, but continue to follow for couple days.  GI was consulted and a decompressive colonoscopy was performed on 12/26.  Report showed Ogilvie syndrome, sessile polyp 3 cm x 2 cm, ulcerations in the cecum.  Repeat abdominal x-ray showed resolution of bowel gas distention.  Because there was no bowel prep, GI recommended repeat colonoscopy after patient was properly prepped before hand.  The patient felt clinically better the next morning, noted resolution of abdominal discomfort.   On 12/28 hemoglobin dropped to 9 and was more closely monitored.  Warfarin was continued to be held.  When hemoglobin continued to fall and dark stools were noted by nursing staff, GI recommended upper and lower scope after bowel prep was done.  Patient had significant difficulty doing this, and by 12/30 was still unable to complete this, while hemoglobin dropped to 7.4.  Multiple discussions were had with patient by GI, Family Medical Clinic team, nursing staff, and his daughter regarding the importance of completing bowel prep so this study can be done.  Patient attempted to complete prep the following several days, however, was unable to.  His hemoglobin remained stable at over 7.0.  After further discussion with patient he decided to forego any further evaluation of suspected GI bleed.  He requested discharge on 01/01, however, there was a snowstorm and discharge was unsafe.  He agreed to stay another night.  He was seen and examined the morning of 01/02 and his exam was unchanged.  He continued to endorse desire to be discharged.  His hemoglobin was stable on discharge.  He was agreeable for a home hospice consult given his decline in renal function and refusal to undergo further medical workup for GI bleed.  He was discharged home in guarded condition.