Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: AST/ALT ratio abnormal, Acute respiratory failure, Alanine aminotransferase increased, Anion gap, Anticoagulant therapy
Clinical narrative: Date of Admission Admit Date: Dec-25-2021  Date of Discharge Date of discharge Jan-02-2022  Allergies CODEINE PHOSPHATE - Not Specified  MORPHINE SULFATE (PF) - Not Specified  fentaNYL - Not Specified  Ativan - Not Specified  Sulfa Antibiotics - Not Specified  Buprenex - Not Specified  Procedure(s) Performed None  Lab Results Jan-02-2022 0904 Point Of Care GLUSTX  142 Jan-02-2022 0532 Hematology WBC  11.5RBC  4.73HGB  14.0HCT  41.0MCV  86.7MCH  29.6MCHC  34.1RDW  12.7RDWSD  39.7PLT  371MPV  9.3AUTONEU%  71.1AUTOLYM%  16.4AUTOMON%  6.3AUTOEOS%  1.7AUTOBAS%  0.4AUTONEU#  8.2AUTOLYM#  1.9AUTOMON#  0.7AUTOBAS#  0.1AUTOEOS#  0.2NRBC%  0.0NRBC  0.0HGB/HCT  2.9IG#  0.47IG%  4.1 Jan-02-2022 0532 Chemistry GLUCOSE  80BUN  13CREAT  0.5MDRD GFR  123NA  138K  3.8CL  103CALCIUM  8.7CO2  27.0OSMO  274.8ANION GP  11.8BUN/CRE  26.0 Jan-01-2022 2140 Urinalysis Department SPECGRAV  1.020U-PH  7.5LEUCOCYT  NegativeNITRITES  NegativePROTEIN  NegativeGLUCOSE  NegativeKETONES  NegativeUROBILIN  4.0BILRUBIN  NegativeBLOOD  NegativeCOLOR  Lt. YellowCLARITY  ClearCULTURE  NCULTIND  <10 WBCWBC  NoneRBC  0-2SQUAM EP  NoneBACTERIA  NoneMUCUS  None Dec-30-2021 0535 Hematology WBC  9.5RBC  4.70HGB  14.0HCT  40.4MCV  86.0MCH  29.8MCHC  34.7RDW  12.1RDWSD  38.5PLT  319MPV  9.4AUTONEU%  67.9AUTOLYM%  17.1AUTOMON%  8.5AUTOEOS%  0.1AUTOBAS%  0.8AUTONEU#  6.5AUTOLYM#  1.6AUTOMON#  0.8AUTOBAS#  0.1AUTOEOS#  0.0SCAN DIF  YNRBC%  0.0NRBC  0.0HGB/HCT  2.9IG#  0.53IG%  5.6 Dec-30-2021 0535 Chemistry GLUCOSE  112BUN  14CREAT  0.7MDRD GFR  84NA  137K  3.5CL  101CALCIUM  8.7ALK PHOS  84CO2  31.4AST  33ALT  59AST/ALT  0.6TL PROT  6.7ALBUMIN  2.8TBILI  0.6DBILI  0.1OSMO  275.0ANION GP  8.1BUN/CRE  20.0 Dec-29-2021 0702 Chemistry CRP  2.30 Dec-29-2021 0702 Serology PROCALC  <0.05 Dec-28-2021 0530 Hematology WBC  7.5RBC  4.34HGB  13.1HCT  38.6MCV  88.9MCH  30.2MCHC  33.9RDW  12.5RDWSD  41.0PLT  216MPV  10.0AUTONEU%  79.0AUTOLYM%  13.1AUTOMON%  6.6AUTOEOS%  0.0AUTOBAS%  0.1AUTONEU#  5.9AUTOLYM#  1.0AUTOMON#  0.5AUTOBAS#  0.0AUTOEOS#  0.0SCAN DIF  YNRBC%  0.0NRBC  0.0HGB/HCT  2.9IG#  0.09IG%  1.2 Dec-28-2021 0530 Chemistry GLUCOSE  118BUN  15CREAT  0.6MDRD GFR  100NA  138K  4.2CL  105CALCIUM  8.8ALK PHOS  76CO2  23.7AST  66ALT  46AST/ALT  1.4TL PROT  6.5ALBUMIN  2.4TBILI  0.6DBILI  0.1OSMO  277.6ANION GP  13.5BUN/CRE  25.0CPK  692 Dec-27-2021 0525 Chemistry CRP  11.70 Dec-27-2021 0525 Serology PROCALC  0.08 Dec-26-2021 0525 Coagulation D-DIMER  1.32 Dec-26-2021 0450 Chemistry MAGNESIU  1.9FERRITIN  744 Dec-26-2021 0450 Serology PROCALC  0.10 Dec-25-2021 2025 Urinalysis Department SPECGRAV  1.025U-PH  6.0LEUCOCYT  NegativeNITRITES  NegativePROTEIN  TraceGLUCOSE  NegativeKETONES  15UROBILIN  0.2BILRUBIN  NegativeBLOOD  Trace-IntactCOLOR  AmberCLARITY  ClearCULTURE  NCULTIND  Not Indicated Dec-25-2021 2000 Microbiology C BLD  No aerobic or anaerobic growth after 5 nights. Dec-25-2021 2000 Hematology WBC  6.5RBC  4.48HGB  13.4HCT  40.2MCV  89.7MCH  29.9MCHC  33.3RDW  12.8RDWSD  42.2PLT  133MPV  9.5AUTONEU%  81.7AUTOLYM%  12.7AUTOMON%  4.9AUTOEOS%  0.0AUTOBAS%  0.2AUTONEU#  5.3AUTOLYM#  0.8AUTOMON#  0.3AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  0.03IG%  0.5 Dec-25-2021 2000 Chemistry GLUCOSE  120BUN  15CREAT  0.7MDRD GFR  84NA  142K  3.8CL  102CALCIUM  8.7ALK PHOS  97CO2  28.7AST  172ALT  56AST/ALT  3.1TL PROT  7.3ALBUMIN  3.3TBILI  0.8OSMO  285.1ANION GP  15.1BUN/CRE  21.4CPK  5065TROPI  <0.017LACTATE  1.50CK-MB  12.0PROBNP  144 Dec-25-2021 1935 Serology COVID  Pos Imaging Results Chest x-ray performed 12/25/21 Findings: Patchy bilateral airspace disease. No pleural effusion. No pneumothoax. Mild cardiomegaly. No acute fracture. Impression: Bilateral airspace disease.  CT head/brain performed 12/26/21 Findings: Mucosal thickening present with maxiallary sinuses. Mild mucosal thickened present with ethmoid sinuses. Mastoid air cells are clear. No calvarial fracutre atherosclerotic vascular calcifications. No evidence for mass or mass effect. No intracranial hemorrhage or abnormal extra-axial fluid collection. No CT evidence of acute infact. The lateral and 3rd ventricles are enlarged out of proportion with the degree of mild to moderate global cerebral volume loss. The 4th ventricle is normal in caliber. Basilar cisterns are patent. Posterior fossa is unremarkable. Impression: 1. No acute intracranial findings. Specifically, no evidence of intracranial hemorrhage. 2. Enlargement of the lateral and 3rd ventricles out of proportion with the degree of mild to moderate cerebral volume loss. No obstructing lession identified. This can be seen with normal pressure hydrocephalus.  Vascular lower extremity doppler performed 12/29/21 Impression: Right posterior tibial vein is noncompressible with absent of flow. Good flow through rest of the right leg venous system. No DVT in the left leg. An anechooic nonpulsatile structure in the medial popliteal fossa measuring 3.3 x 4.4 cm is seen.  Functional Status* Impaired mobility  Mental Status* Impaired Cognition  Social History tobacco use Unknown If Ever Smoked  marital status Married  Health Concerns Pneumonia  Hypoxia  Acute respiratory failure  COVID-19  Vital Signs Jan-02-2022 1152 T 98.5 HR 80 RR 20 BP   135 / 77 O2Sat 95 Jan-02-2022 1151 T 98.5 HR 80 RR 20 BP   135 / 77 O2Sat 95 PHYSICAL EXAM Constitutional: Patient is a 66 year old female, who is pleasant, and cooperative during exam. In no acute distress. Cardiovascular: Heart rate and rhythm is regular. No murmurs or clicks noted. Radial, dorsalis pedis, and posterior tibial arteries are 2+ bilaterally. No peripheral edema noted. Respiratory: Lungs are clear to auscultation bilaterally. No wheezes or rales noted. No accessory muscle use. She is currently on room air GI: Normoactive bowel sounds. Abdomen is soft, non-tender to palpation. No guarding or rebound tenderness. Psych: Patient is alert and oriented. Mood and affect is appropriate.  Hospital Course Patient is a 66 year old female, who presented to the emergency room on 12/26 due to shortness of breath. She was also having some increased weakness while at home. She had also fallen and her caregiver was unable to help her get up. She was found to be COVID positive and requiring supplemental oxygen, as well as having rhabdomyolysis and admitted to the hospital. She was started on remdesivir and dexamethasone for her COVID pneumonia and was started on IV fluids for her rhabdomyolysis.  Her oxygen requirments remained low during her hospitalization though they did elevate during the middle of her stay. She began to develop acute leg pain as well, and lower extremity doppler was performed, finding a right sided DVT. She was started on Eliquis for treatment of the DVT.  The few days prior to admission, it was noted that her oxygen saturation had been steadily increasing from 2L to 4L. She was monitored closely for an additional couple days to ensure that this did not progress further. On the day prior to discharge, her oxygen saturations remained stable and actually improved, and her foley catheter was removed as she did not have one at baseline. That night, she was having some difficulties with urination, and bladder scan was done showing 800cc of residual urine. Foley catheter was placed again.  On day of discharge, she was placed on room air and had no desaturations and maintained her oxygen saturation in the 90%s. She was discharged home into the care of her husband.  Condition at Discharge Stable  Discharge Medications ACETAMINOPHEN 650 MG ORALLY EVERY 4 HOURS AS NEEDED for FEVER OR MILD PAIN 1-3 ON PS APIXABAN 10 MG ORALLY TWICE DAILY (ePrescribed by DO RESIDENT on Jan-02-2022 1023) ARIPiprazole Oral Tablet 2 MG 2 MG ORALLY ONCE A DAY ASPIRIN LOW DOSE 81 MG ORALLY ONCE A DAY levothyroxine 100 mcg tab 100 MCG ORALLY EVERY MORNING Memantine HCl Oral Tablet 10 MG 10 MG ORALLY TWICE DAILY metFORMIN HCl ER (MOD) Oral Tablet Extended Release 24 Hour 500 MG 1000 MG ORALLY WITH EVENING MEAL Omeprazole Oral Capsule Delayed Release 20 MG 20 MG ORALLY DAILY AT 0700 POLYETHYLENE GLYCOL 17 GM ORALLY ONCE A DAY Terbinafine HCl Oral Tablet 250 MG 250 MG ORALLY ONCE A DAY Discharge Disposition Discharge to home with home health  Plan Assessments - Acute hypoxic respiratory failure, secondary to COVID-19 Pneumonia - COVID-19 Pneumonia, secondary to Sars-CoV-2, unlikely due to secondary bacterial infection - Acute rhabdomyolysis, unknown time down, CPK 5065 on admission, improved to 1913 on 12/27 - Right lower extremity DVT, started on Eliquis - Left popliteal baker's cyst - Unilateral weakness, Right upper and lower extremities - Possible normal pressure hydrocephalus with bilateral third ventricle enlargement, per CT 12/26/2021 - Possible history of recent stroke with residual weakness. - Factor V deficiency - Acute Hypokalemia, K 3.3 on admission, resolved  Plan: Patient will be discharged today. She is doing well and is no longer requiring supplemental oxygen. She and her family are eager for her to return home. She will be discharged home with a foley catheter. She did not have one at home prior. After pulling foley catheter yesterday, overnight it was noted that she had 800cc in her bladder that she was unable to urinate out, and she was catheterized. Would recommend that she see urology for further discussion. She will be sent home with home health and will be seen by skilled nursing, physical therapy, and occupational therapy, in hopes of building back up her strength. Due to the DVT that was found on ultrasound during her hospitalization, she has been started on Eliquis, 10mg twice daily. On the 6th, she will need to stop taking 10mg twice daily, and begin taking 5mg twice daily of the Eliquis. She should also see her primary care provider for a hospital followup.