Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Blood alkaline phosphatase increased, Blood calcium decreased, Blood culture negative, Blood folate normal, Blood iron decreased
Clinical narrative: Pt presented to acute care on 5/21/21 following 2 weeks of SOB, intermittent low grade fever and fatigue.  Labs and chest XR ordered.  Diagnosed with UTI and placed on Omnicef 300 mg BID x 7 days.    Follow up in clinic on 5/24/21 for continuation of symptoms:  SOB, intermittent low grade fever/chills, dry cough.   Pt prescribed albuterol and labs ordered.  Follow up in clinic on 5/26/21 for ongoing SOB, intermittent low grade fever, dry cough, anemia, abnormal liver function.  Ordered ECG 12 lead and sent to emergency department.  Admitted to hospital 5/26/21 :  During hospitalization patient was diuresed with Bumex, she put out a net of approximately 2.4 L and then developed an AKI suggestive of intravascular depletion.  Diuretics were stopped, confirmed that BNP down trended and was within normal range. Patient had negative troponins throughout hospitalization.  Her free T4 and TSH was within normal limits.  She had mild electrolyte disturbances secondary to diuretics which were replaced.  She had a respiratory viral panel completed, did not identify any source.  Patient is Covid negative.  ANA and ANCA screen were sent out unfortunately they will be delayed.  #SVT: Patient went into an SVT rate of 150 required adenosine which showed underlying sinus rhythm.  Started on amiodarone drip briefly which did help maintain sinus rhythm although she had hypotension with that.  Cardiology was consulted during hospitalization.  Despite SVT troponins remain negative.  TSH and free T4 within normal limits.  #Acute on chronic combined systolic and diastolic heart failure #Suspected viral cardiomyopathy #Acute respiratory failure with hypoxia Patient remains with good saturation off oxygen.  She is net -2.0 L from diuresis.  Weight is down approximately 4.4 kg.  Started on metoprolol, unfortunately due to hypotension had to decrease the dose to 25 mg daily.  Aspirin 81 mg daily was provided.  Currently holding diuretics but may need to be reassessed for restarting this in the future.  ANA and ANCA pending.  #Leukocytosis #Increase inflammatory markers #Sepsis with organ dysfunction No clear-cut source of infection but she did have pyuria with leukocyte esterase.  She could also have had atypical pneumonia.  The concern is that patient could have an underlying inflammatory process versus autoimmune process contributing to it end organ damage.  At this point I cannot tell so started empiric treatment with ceftriaxone during hospitalization, complete 5 of 7 days course as well as 3 of 3 days of azithromycin.  Despite this leukocyte continues to be elevated and inflammatory markers continue to be elevated.  #Hypertension: Patient was briefly hypotensive in setting of amiodarone, metoprolol continue to 25 mg after discontinuation of amiodarone.  Will need to be retitrate to goal-directed therapy.  #Hypothyroid: TSH and free T4 within normal limits given the tachycardia holding levothyroxine for 5 days  #Suspected UTI Day 5 of 7 of ceftriaxone currently, initially had 50?100 WBCs positive for pyuria, leukocyte esterase positive no bacteria seen.  #Atypical pneumonia suspected: Completed 3 days of azithromycin  #Elevated LFTs #Elevated alk phos: Unclear as to potential source other than congestive hepatopathy LFTs normalized alk phos downtrending  #Anemia of chronic disease: Possible viral syndrome unclear etiology at this point.  There may be some underlying iron deficiency.  No indication for transfusion during this hospitalization. Patient remained on sodium restricted 2 g daily, and 2 L of fluid restriction diet.  She is a full code and enoxaparin was used for DVT prophylaxis. Hospital transfer today, 6/2/2021 to St. Michaels with no clear unifying diagnosis.  Maybe a pericarditis:  Patient continues to have ST changes on EKG, elevated inflammatory markers, significant JVD, evidence of heart failure on echocardiogram, after speaking with cardiology will likely need a right heart cath