Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Fibrin D dimer increased, Gait disturbance, Haemoglobin decreased, Hepatic cirrhosis, Hypotension
Clinical narrative: Per admitting documentation: Patient is 74 years old with past medical history of depression, GERD, hyperlipidemia, irritable bowel syndrome, migraine, depression, ectopic pregnancy presented to the hospital with a chief complaint of shortness of breath associated with cough that has been ongoing for over a week.  Patient was diagnosed with COVID a week ago.  Patient has noticed becoming progressively having generalized weakness over the last 1 week and having difficulty ambulating due to the generalized weakness.  Patient was found to be hypoxic on presentation.  She was placed on 3 L of oxygen.  On presentation patient had a CT angio done that was negative for PE.  It did show moderate ascites.  When seen, patient was found to be hypoxic on presentation.  She was placed on 3 L of oxygen.  On presentation patient had a CT angio done that was negative for PE.  It did show moderate ascites.  When seen, patient was resting in bed comfortably.  Patient states she had fever previously in the initial phases when she got the COVID but she is not having any fevers currently.  Otherwise patient has no chills, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, difficulty urination, dysuria.  Patient is having abdominal distention but there is no abdominal pain.   In the ED, patient was given a dose of Decadron 6 mg.  Patient was given a dose of lactulose.  Patient was given a dose of rifaximin.   Clinical Summary Covid-19 pneumonia  Acute hypoxic respiratory failure Possible superimposed bacterial pneumonia  -Covid positive 10/6 (inpatient test) -echocardiogram 10/5 LVEF 65%, grade 1 diastolic dysfunction -overnight 10/8 had desaturation to low 80s, briefly required 9L oxymask, today is back down to 5L, suspect in part d/t worsening pulm edema -  10/9 transferred to ICU for acute worsening of hypoxia to 12L, started on IV lasix BID - CT shows no embolic dz, diffuse GGO, pulm edema, worsening ascities noted  - 10/10 early am intubated for worsening hypoxia -10/11 improving FiO2 requirements on vent  -10/12 overnight received albumin/500cc bolus, remains on 5mcg levo. Sputum cx: Gram neg rods - continue MV, ARDSnet protocol  - serial ABG - continue precedex, fentanyl for sedation - continue cefepmie - continue decadron - remdesivir discontinued on day 4 d/t rising Cr and LFTs    Hypotension - developed hypotension following intubation - remains hypotensive, stable pressor requirements  - suspect related to sedation though difficult to exclude underlying sepsis vs ? HRS - Bcx NGTD - continue cefepime - continue levo gtt, target map 65 - home antihypertensives on hold    Lactic acidosis Lactate remains elevated at 4.3, no improvement w/ 500cc bolus + albumin overnight, suspect related to developing HRS 10/12: lactate remains elevated  - trend lactate  - maintain pressor support as above    AKI Oliguria  Cr up to 1.23, oliguria noted throughout the day today. Suspect ATN secondary to hypotension, though in the setting of cirrhosis would have to consider HRS 10/12: Cr continues to worsen, remains oliguric, ? HRS. Transfer to Care Center for anticipated RRT needs  - monitor CMP - mointor strict I/O - avoid nephrotoxic agents  - remdesivir discontinued  - may need transfer for RRT needs, have d/w family, agreeable to pursue transfer if afternoon labs show worsening Cr  - prefer Care Center for tertiary center    Pneumothorax? XR this am showed possible R apical ptx, repeat XR this afternoon without obvious ptx, suspect this was probably artifactual. D/w pulm    LUE swelling - US duplex neg for DVT    Coagulopathy  DIC panel checked today, found to have high D dimer, fibrinogen borderline. INR is 3.1. Noted to have extensive ecchymosis. Coagulopathic 2/2 cirrhosis, though would not exclude developing DIC. Still holding off on dvt chemoprophylaxis d/t bleeding risk (note hx of EV)  10/12: Fibrinogen borderline, some oozing around IV sites noted. INR 3.2->2.1 after vit K - consider cryo/ffp, will recheck fibrinogen this afternoon   Acute on chronic anemia  Hbg 9.1->7.9 overnight though did receive 50g albumin and 500cc NS overnight, likely dilutional. No signs of active bleeding, though given her coagulopathy in the setting of known EV, would benefit from facility w/ GI support  - monitor H/H - transfuse for Hbg <7 - check LDH/hapto - pending at the time of discharge  - has been typed/screened    Hepatic cirrhosis  Thrombocytopenia, chronic  Ascities Chronic anemia History of EV Hx of MASH cirrhosis dx in 2020. Had EGDin 2020 that revealed large EV. Currently followed by hepatology at Care Center. LFTs here have been slowly up trending, may be 2/2 covid 19 infection vs remdesivir vs mild decompensation. On admit lasix/aldactone were held d/t clinical dehydration, over the last ~24 hrs she has had progressive ascities with evidence of volume overload on imaging. Was previously on heparin for DVT ppx however was discontinued d/t extensive ecchymosis in the setting of her chronic thrombocytopenia 10/11: LFTs continue to trend up, have Dcd remdesivir  10/12: LFTs improving after stopping remdesivir, RUQ US w/ just cirrhotic findings  -continued home rifaximin and lactulose -decrease lactulose back to 10g (diarrhea this am) -lasix on hold in the setting of hypotension  - Gen surg following for eventual para pending hemodynamic stability  - prior to para may need FFP - monitor CMP and CBC daily  - given progressively uptrending LFTs will check RUQ US - MELD-NA = 14   Mild lower extremity edema, POA, chronic HFpEF - mild decompensation  -echo 10/5 with grade 1 DD -now w/ some progressive LE edema, ascities as above - diuresis/GDMT on hold d/t hypotension  - strict I/O   Generalized weakness Protein malnutrition -nutrition following, on TF