Age: 64.0
Sex: M
Vaccine: COVID19-2, FLU4
Symptoms: Small intestinal obstruction, Troponin increased, Urinary retention, Vomiting
Clinical narrative: Discharge Provider:  Primary Care Provider:  Admission Date: 12/26/2022 Discharge Date: Dec 28, 2022 COVID positive 12/24/2022 PRESENTING PROBLEM: Small bowel obstruction [K56.609] Respiratory failure with hypoxia [J96.91]   HOSPITAL COURSE: Pt. is a 64 y.o. male with past medical history including esophageal adenocarcinoma s/p esophagogastrectomy (03/2022), chronic cancer related pain, BPH, HLD, and diverticulosis who was transferred on 12/26/2022 from Hospital for evaluation by surgical oncology for recurrent small bowel obstruction.    The patient had been recently admitted from 12/16/2022 to 12/20/2022 for small bowel obstruction thought to be secondary to a large diaphragmatic hernia, which was successfully medically managed. He re-developed symptoms of constipation and bloating on 12/23/2022 and presented to ED. CT abdomen/pelvis was ordered due to the abdominal symptoms, and this revealed an evolving high-grade partial small bowel obstruction with transition point in the LUQ, Bochdalek type diaphragmatic hernia in posterior left chest, intrathoracic stomach, and moderate to severe pancreatic atrophy. The patient had been medically managed and began having formed bowel movements 12/25/2022. Surgery was consulted at hospital who recommended transfer to for evaluation by surgical oncology (who performed his esophagogastrectomy) for definitive surgical management. The patient was evaluated by the surgical oncology team during his admission and they felt that based on the patient's symptomatic resolution and formed bowel movements, there were no immediate surgical needs. His diet was advanced to fulls prior to discharge. He is not to advance his diet past fulls until following-up with the surgical oncology team.    On 12/27/2022, the patient experienced sudden onset shortness of breath and left-sided chest pain. EKG demonstrated nonspecific ST changes. Troponin had a delta of > 500. Protocol was activated. CTA was negative for PE or other acute processes. Cardiology was consulted. An echocardiogram was obtained that demonstrated  LVEF 45% and inferolateral wall akinesis. The patient subsequently underwent left heart catheterization which did not show any significant stenosis of the coronary arteries. The patient's symptoms resolved and did not recur. This was a likely type II myocardial infarction secondary to hypoxia, myocarditis, or coronary vasospasm.    On presentation to ED, the patient had also complained of new onset left wrist weakness. CT head, CT cerebral perfusion, and CT angiography head/neck were negative for acute abnormalities. MRI brain was obtained which was unremarkable. MRI spine was negative for acute abnormalities, but did demonstrate heterogeneous signal with mild enhancement in the sacrum and iliac bones concerning for possible metastasis. Neurology recommended outpatient follow-up for EMG testing for likely compressive neuropathy.    The patient was found to be Covid-19 positive at Hospital. He was hypoxic during hospitalization requiring HFNC briefly at hospital and BiPAP briefly during the episode on 12/27/2022 mentioned above. He received treatment with decadron and remdesivir. The patient was discharged home with 2L NC supplemental oxygen requirement with activity and sleep. He was provided a five day course of decadron at discharge, as well.    The palliative care team was also consulted during the patient's hospitalization to assist with management of his chronic cancer pain. He was discharged on his previous home regimen.    On discharge, the patient was hemodynamically stable. He was given instructions on the full liquid diet and provided his home oxygen concentrator. All questions/concerns were addressed prior to discharge.