Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Fibrin D dimer, Glycosylated haemoglobin increased, Gout, Gouty arthritis, Gouty tophus
Clinical narrative: HOSPITAL COURSE: Briefly, this is a hmong speaking 72 yo w/ PMH significant for T2DM, HTN, reported gout, coming in for concerns of fatigue of two days PTA. Found to be hypoxic and COVID positive, admitted for further cares. For more detail, including PMH, PSH, PFH, Social Hx and further info please see admission H&P and daily progress notes.   Hospital course dictated by problem:   Acute hypoxemic respiratory failure COVID-19 PNA Suspect superimposed bacterial PNA   -Underwent series vaccination, no booster. -Admitted on supplemental oxygen, steroids and anticoagulation based on D-dimer and institutional protocol. -He did have an elevated procalcitonin on admission concerning for superimposed bacterial pneumonia and so was also started on Rocephin and azithromycin. Completed appropriate antibiotics here. -He had slight improvement in oxygen needs but essentially plateaued around day six hospitalization without any worsening. -He repeatedly requested to go home and family was comfortable with this.  Because of this, improved symptoms, improved oxygenation, appropriately downtrending procalcitonin, stable vitals we discharged him home. -Consider anticoagulation at discharge but with his IMPROVE score <4 and w/ admit d-dimer <1 did not discharge on anticoagulation. -Because his age-adjusted D-dimer was unremarkable did not pursue CT PE work-up. -Discharged on steroids, home oxygen, advisement of close PCP follow-up.  Also wrote for home cares.   Transient episode of confusion of unclear etiology 1/2 BC's positive for staph epi, likely contaminant   -2/16 became altered. Vitals were stable. Exam was otherwise non-focal. -UA was clear, head CT was unremarkable. No white count.  -1/2 BC's + for staph epi which was felt to be contaminant based on clinical findings without concerns of dermatologic findings of infection; no hx of prosthetics/implantables, etc.; repeat BC's NGTD. -His symptoms spontaneously resolved the following day without intervention. -Son was updated and patient was that we did not have a clear explanation for what happened.  Advised to seek immediate medical care should he have recurrent similar episodes.   Suspect acute on chronic gout, timing of gout flare uncertain Gouty arthropathy with tophaceous gout   -He had foot pain here with findings of tophaceous gout, x-ray with findings concerning for gouty arthropathy as well. -As he was already on Decadron for COVID we increased from 6 mg to 9 mg (roughly 60 mg prednisone equivalent). -Was noted to have an uptrending CRP here that we felt was likely explanation particularly in the setting of what appears to be extensive gout of his feet (see prior images, multiple tophaceous deposits along the left foot and base of right 1st metatarsal).  Down trended with increase in steroids. -Advised on discussing with PCP for consideration of urate lowering therapy, and should have haplotyping if this is to be considered.   IDDM2   -A1c 10.9 here.  Appears uncontrolled. -Increase PTA Lantus slightly based on blood sugars here, A1c, for patient-sliding scale -Patient and son informed that he needs to closely follow-up for this to be evaluated.   Thrombocytopenia, Resolved   -On presentation platelets down to 143.  Suspect secondary to viral infection. Rechecks wnml.   Elevated liver enzymes   -AST 51, alk phos 146, T bili 2.1 noted on presentation.  Likely also secondary to viral infection. Recheck improved.    Mild leukocytosis   -noted day of discharge upon increasing steroid for gout, likely 2/2 corticosteroid use.   HTN   -PTA lisinopril, for hypertension or for diabetes? -His blood pressures were soft here and so he was advised to hold this and discuss with his PCP about whether or not to continue, with averaging between 100-130 systolic with holding.   HLD   -Continue PTA statin.