Age: 54.0
Sex: F
Vaccine: COVID19
Symptoms: Blood folate decreased, Blood potassium increased, Blood thyroid stimulating hormone decreased, Brain natriuretic peptide increased, COVID-19
Clinical narrative: DISCHARGE DIAGNOSES:   Shortness of breath with COPD exacerbation with COVID-19 positive status AKI on CKD stage IV with hyperkalemia Anemia chronic systolic heart failure, hypertensive urgency      HOSPITAL COURSE:     54 y.o., female, w a PMH of HFrEF, severe COPD, asthma, stage IV CKD, recent d/c for COPD exacerbation on 12.28, who was admitted on 1/15/2022, with SOB, COVID +.  Patient was recently discharged from north memorial hospital on December 29, 2029 with diagnosis of pneumonia, COPD exacerbation     Shortness of breath with Initially concern for LV thrombus on echo this admission with history of chronic systolic heart failure, hypertensive urgency on presentation Echo 1/16 with possible LV thrombus -Started on heparin drip however - cardiac MRI completed-and there is no LV thrombus so heparin drip was stopped on 1/18/2022 Had chest pain earlier now resolved troponin elevation 2/2 demand ischemia -Mildly elevated troponin may due to hypoxia/demand ischemia.  EKG is nonischemic. Echo without new WMA, EF 35 to 40% with moderate global hypokinesis it is not new finding Continue aspirin Continue atorvastatin, carvedilol, Imdur Not on an ACEi due to renal dysfunction Likely shortness of breath from pulmonary issue as below    Had a hypertensive urgency earlier continue blood pressure medications- amlodipine dose increased.  Per last admission per pharmacy med rec, patient was previously rec'd for carvedilol on prior discharge summaries, but per med refills, she has actually still been taking metoprolol for report of poor tolerance to coreg however unclear whether this is accurate as do not seen any outpatient notes stating intolerance, however there is note of concern for polypharmacy and she was referred by PCP to their clinical pharmacist on 12/14-this admission also patient came with metoprolol rather than carvedilol Metoprolol was changed to carvedilol this admission again for additional benefit for blood pressure management       AKI on Stage IV CKD with hyperkalemia Previous urine studies have been consistent with hypertensive nephrosclerosis with bland urine micro and minimal proteinuria. Prior  Admitting Cr 2.80 is improved from last at d/c (Baseline Cr since 10/2021 is mid 3).  Previous urine studies c/w htn nephrosclerosis. - Avoid nephrotoxic meds if able.  Potassium was 5.5 1/16 AM improved to 5.2 with lasix, rebounded to 6.0 but improved to 5.2 without intervention, she received shifting with insulin/dextrose and calcium gluc after lab was drawn but before result returned  Nephrology consult appreciated for worsening kidney numbers-  follow-up with nephrology clinic in 2 months however prior attempts to set up outpatient follow-up had been unsuccessful  NAGMA: secondary to chronic kidney disease.- Continue bicarb 650 mg daily  Hold torsemide 20 mg daily- check BMP in 1-3 days and if creat stable then resume home torsemide       COVID Pneumonia COVID-positive on January 15 COPD with acute exacerbation  Acute respiratory failure with hypoxia  Patient was admitted in December 2021 for COPD exacerbation Patient got to regular doses and booster dose of vaccine  chest x-ray no pneumonia Elevated BNP in the setting of worsening renal function also could have some pulmonary congestion as patient had hypertensive urgency Continue bronchodilator - Steroids- prednisone  was started (now off O2, so no COVID indication) steroids indication is for COPD exacerbation  - Antibiotics- doxycycline 100 twice daily x5 days last date January 20 - Continue fluticasone-vilanterol daily (on mometasone-formoterol 2puff BID PTA) - Continue PTA montelukast qHS Elevated D-dimer -  patient do not have DVT and pt is not hypoxic.  CTA not done due to CKD           Acute on chronic macrocytic anemia Last admit- Macrocytic with MCV 101 on folic acid PTA. Etiology not entirely clear. Possibly multifactorial including CKD. B12 low normal, folate low (on folate PTA). Iron suggestive of anemia of chronic disease. EtOH mildly elevated on presentation during December 2021 admission - Continue PTA folate 1mg  - PTA Cyanocobalamin 100mg daily - Transfuse for hgb <8 given her cardiac hx and acute hypoxia     Low hemoglobin 1/18 less than 7 no overt bleeding.   1 unit of blood transfusion planned 1/18 and repeat hemoglobin stabilized Stool for occult blood came back positive.  Discussed with GI on-call  todfay patient had low hemoglobin while on heparin drip.  Now heparin drip is stopped and hgb is stable.  Per GI patient had EGD and colonoscopy in 2021 with no acute finding. No immediate plans for scopes.   Started on PPI and patient will follow up with GI     Low TSH setting of acute illness Repeat in few weeks Clinically does not seem to be hyperthyroid