Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Pallor, Pancytopenia, Pathological fracture, Peripheral swelling, Pneumonia
Clinical narrative: Hospitalized (1.4.22 - still admitted currently); COVID-19 positive (1.4.22  vs 12/31/21 positive home test -self reported); fully vaccinated PLUS Booster - pfizer x3 H&P: CHIEF COMPLAINT: COVID + Pneumonia AKI Pancytopenia   ASSESSMENT / PLAN:   Acute on chronic hypoxic respiratory failure COVID-19 Pneumonia - Onset of symptoms ~ 7 days ago, reports positive at home COVID test 5 days prior to admission - S/p mAb on 1/2/22  - COVID 19 PCR + on 1/4/22 - Influenza A/B and RSV negative - BNP elevated 13,582 - CXR 1/2 - slight interval worsening of bilateral airspace opacity/pneumonia - CXR 1/4 - stable persistent mild bronchopneumonia - On 2.5L O2 at night at baseline - increased needs at home -- > currently on 5L NC - S/p decadron in the ED, continue to complete 10 days - Not able to do Remdesivir 2/2 renal failure - Consult ID given high risk 2/2 pancytopenia - Nebs PRN - Continuous pulse ox   AKI on CKD - Creat 1.79 on presentation, creat was 1.3 on 12/14/21 - S/p 1L IVF in the ED - Avoid nephrotoxins - Check UA - Monitor   Multiple myeloma - Diagnosed in 2011  - S/p revlimid and dexa in 2011 - S/p 2 cycles CyBorD - stopped 2/2 toxicity - Changed to Velcade and dexa, possible addition of dara in near future - Referred to orthopedic surgery and Rad onc as outpt due to pathologic fracture seen in PET scan - Patient of Dr    Pancytopenia - Monitor and transfuse for Hgb < 7, platelets <10 or <30 if bleeding   Pulmonary arterial hypertension Right sided heart failure - NYHA functional class 1 - Last echo 10/28/21 with EF 63%, severe RV dilation and severe decreased function, flattened systolic septum, RVSP at least 95. Moderate tricuspid regurgitation - Follows with Dr as outpatient - will consult - BNP elevated 13,582 - Hold torsemide and aldactone  - IV albumin followed by IV lasix x 1 now. Monitor daily diuresis needs  - On Sildenafil 20mg TID, ambrisentan, selexipag - Was on midodrine - recently stopped - Daily weights, monitor I/Os   Bilateral LE edema - Worsening over past 2 days - Likely 2/2 above - Diurese and monitor - Pt is on eliquis   First degree AV block  - EKG in ED: sinus bradycardia with heart rate 58, first-degree AV block. T-wave inversions in V1 through V5, inversions in V3 to V5 were present on prior EKG from October, but the 1 in V2 is new. Worsening ST depression in the lateral leads - Troponin flat 27 -- > 25 - Denies chest pain/pressure at time of visit - Curbeside with cards, overall EKGs appear similar to 2019, await Echo results and if changes then will place formal consult   Atrial fibrillation - On amiodarone and eliquis   HTN - Continue home meds - Monitor    HLD - Not on statin   OSA              - Does not wear CPAP              - On chronic 2.5L home O2 at night   DVT prophy              - On eliquis   DNR/DNI   SUBJECTIVE: Patient is a 75 year old female with PMH significant for multiple myeloma, pulmonary HTN, right sided heart failurem Atrial fibrillation, CKD,HLD, depression, who presented to the ER due to shortness of breath. On presentation to the ED pt was hypoxic to 83-86% on room air and was placed on 4L O2 improving to mid 90s. COVID PCR positive. Labs notable for pancytopenia, elevated BNP. EKG with sinus bradycardia with heart rate 58, first-degree AV block. T-wave inversions in V1 through V5, inversions in V3 to V5 were present on prior EKG from October, but the 1 in V2 is new. Worsening ST depression in the lateral leads. Troponin x 2 flat 27 -- > 25. Patient was given 1L IVF, albuterol and decadron. Patient is being admitted for further treatment.    Patient seen in the ED, she reports onset of symptoms ~ 1 week ago, had a positive at home COVID test ~ 5 days ago. She has been experiencing worsening shortness of breath, chest tightness and increased oxygen needs. She wears 2.5L oxygen at night at baseline due to OSA (does not wear CPAP), over the last several days she has been needing to use her oxygen during the day. Reports O2 levels dropping to 70-80s on room air. Reports productive cough of yellow/gray phlegm. She was evaluated in the ED on Sunday, she received monoclonal antibodies and was instructed to increase O2 to 3L during the day/night. She was doing ok with that but needed to increase O2 more today due to low O2 sats. She feels that her breathing and chest tightness have improved after albuterol. Reports chills but has not been checking temperature. Reports nausea but no vomiting. She has chronic intermittent diarrhea but Sunday diarrhea seemed to worsen and she had several bouts of diarrhea, has not had a BM since yesterday. Reports mild abdominal pain. Denies urinary or bleeding concerns. Reports worsening of BLE swelling over the past couple of days. Appetite has been fair to poor.    History was provided by the patient.   Review of Systems  Constitutional: Positive for appetite change, chills and fatigue. Negative for diaphoresis and fever.  HENT:   Positive for congestion and rhinorrhea. Negative for mouth sores, sore throat, trouble swallowing and voice change.   Eyes: Negative for visual disturbance.  Respiratory: Positive for chest tightness, cough, shortness of breath and wheezing. Negative for hemoptysis.   Cardiovascular: Positive for chest pain and leg swelling. Negative for palpitations.  Gastrointestinal: Positive for abdominal pain, diarrhea and nausea. Negative for abdominal distention, blood in stool, constipation and vomiting.  Genitourinary: Negative for difficulty urinating, dysuria and hematuria.   Musculoskeletal: Negative.  Negative for extremity weakness.  Skin: Negative for rash and wound.  Neurological: Negative for dizziness, headaches, light-headedness, numbness, paresthesias and extremity weakness.  Psychiatric/Behavioral: Negative. Objective    OBJECTIVE: BP (!) 104/45  | Pulse 57  | Temp 37 °C (Oral)  | Resp 20  | Wt 91.8 kg  | SpO2 93%  | BMI 32.67 kg/m²   Body surface area is 2.07 meters squared.  Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is ill-appearing. She is not toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are dry.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Bradycardia present.     Heart sounds: Murmur heard.     Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Wheezing and rhonchi present. No rales.     Comments: On 5L NC Diminished at bases Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is abdominal tenderness (mild LLQ). There is no guarding or rebound.  Musculoskeletal:        General: No tenderness. Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Right lower leg: Edema present.     Left lower leg: Edema present.  Skin:    General: Skin is warm and dry.     Coloration: Skin is pale.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.    1/10/22 Infectious Disease Progress Note: ASSESSMENT/PLAN: Diarrhea, unspecified Assessment & Plan o Has been a chronic problem for patient but had been worsening. 5x today o Enteric pathogens 1/5 and C difficile toxin 1/5 negative    Multiple myeloma  Assessment & Plan o Most recently treated with Velcade and dexamethasone o Places her at increased risk for complications and COVID-19 infection   * Acute hypoxemic respiratory failure   Assessment & Plan o Secondary to COVID-19 infection, PCR positive 1/4, remdesivir completed 1/9, mab 1/2 o Remains on O2 via HFNC  o 1/5 chest CT with bilateral infiltrates with area of ground-glass opacities and some small areas of consolidation within the lower lobes, particularly left lower lobe, no areas of cavitation and no effusions; suspect all changes due to COVID-19 infection  o 1/7 CXR-some increased infiltrate/consolidation in LLL o Sputum 1/7 gram stain polymicrobial, cult nl respiratory flora o Completed remdesivir 1/9   PLAN o PJP prophylaxis started by pulmonary team due to prolonged taper o Continue to monitor off additional antibiotics     Following Please call with questions for Dr.  Infectious Diseases 1/10/2022     Subjective:   Interval events: sputum culture from 1/7 final with normal resp flora. Remains afebrile. Completed remdesivir 1/9. Remains on HFNC. ddimer up to 2080. CRP trend favorable. US extremities 1/10 unchanged nonocclusive right popliteal vein thrombus favored to be subacute/chronic.    Feels more tired today. Denies change to work of breathing. 5 Bm thus far today. No abdominal pain Allergies: Amoxicillin-pot clavulanate, Asacol [mesalamine], Augmentin, Lisinopril, Penicillin g, Penicillins, and Verapamil   Review of systems: SEE HPI     Objective:   Vitals: BP 126/51  | Pulse 69  | Temp 36.8 °C (Oral)  | Resp 20  | Ht 1.689 m  | Wt 94.8 kg  | SpO2 90%  | BMI 33.23 kg/m²     Gen: AOx3, NAD Respiratory: coarse, HFNC Cardiovascular: regular rate, edematous Abdomen: soft, mildly distended, nontender MSK: edematous Skin: not diaphoretic, no visible rash Psych: mood appropriate, cooperative, answers all questions