Date of Admission: 9/22/2023   Date of Discharge: 10/3/2023   Issues to be Addressed at Follow-up: 1.  Workup of large kidney mass, likely renal cell carcinoma 2. Workup up left lung nodule, possible metastatic disease 3. Any chest pain or pressure? 4. Kidney function okay? 5. Breathing okay?   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   9/22/2023 11:53 AM TRIGLYCERIDES In process --   9/22/2023  5:40 AM TRIGLYCERIDES In process --       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 PNEUMONIA   ? MULTIPLE PULMONARY NODULES   ? ACUTE CHF, UNSPECIFIED   ? ACUTE PULMONARY EDEMA   ? ACUTE NON ST ELEVATION MI   ? ABNL LIVER ENZYMES   ? ACUTE RESPIRATORY FAILURE   ? NONTRAUMATIC ACUTE KIDNEY INJURY   ? ELEVATED TROPONIN I   ? RENAL MASS   ? ATRIAL FLUTTER, UNSPECIFIED   ? ANEMIA     Resolved Hospital Problems   Diagnosis Date Resolved ? HYPONATREMIA 09/25/2023 ? LACTIC ACIDOSIS, UNSPECIFIED 09/23/2023 ? SHOCK, UNSPECIFIED 09/23/2023     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions.   Hospital Course and Significant Findings: Patient is a 72 Y male with pmh of HYPERTENSION, incomplete data base of pmh as pt usually gets medical care in another country, who presented  to the ED with hypoxemic resp failure, fever, with agonal breathing and oxygen saturation of 41%.  Pt covid positive.  Pt intubated, admitted to ICU where he developed PEA and had CPR.  CT did not show PE but did show large left renal mass, very likely renal cell ca.  Chest CT showed 2.2 cm nodule, possibly metastatic disease.  Trops very high, c/w NSTEMI.  Echo with good ef, nl valves.  Pt diuresed, extubated.  Pt with some AKI, imrpoved.  Also with atrial fibrillation, asa continued and not systemically anticoagulated due to very high bleeding risk with large renal mass.  oxygen weaned to off.  Pt treated for possible bacterial pneumonia as well, but less likely. Pt stable for d/c home.  Pt does not have insurance so unable to schedule follow up.  The patient and family know of importance of follow up.  Also, I have recommended the family hire physical therapist to come to house. Per progress note: Patient Active Hospital Problem List:  ACUTE CHF, UNSPECIFIED (9/25/2023)  ACUTE RESPIRATORY FAILURE (9/22/2023)  ACUTE PULMONARY EDEMA (9/25/2023)   Assessment: Suspect  (flash) pulmonary edema.  HfpEF on echo.  No pulmonary embolism on CTA.   Concern for pulmonary edema, now seem euvolemic.  Plan: Lasix 20mg po daily ..  Metoprolol.  Lisinopril.  Norvasc.      PNEUMONIA   Assessment: Received Vanco and zosyn for pna earlier in hospitalization, transitioned to ceftriaxone, has sputum production and wet cough.   Plan:  Completed abx.   COVID-19 DISEASE (9/22/2023)   Assessment: Completed remdesivir.  Thought that respiratory failure was related to pulmonary edema   Plan: Enhanced respiratory precautions, pt to remain isolated for 20 days from onset of symptoms (d/w daughter)   NONTRAUMATIC ACUTE KIDNEY INJURY (9/22/2023)   Assessment: Cr improved    Plan: Avoid nephrotoxins.      ACUTE NON ST ELEVATION MI (9/23/2023)  ELEVATED TROPONIN I (9/22/2023)   Assessment: Troponin up to 17000, trended down.  Concern for NSTEMI, not a candidate for intervention given risk of bleeding.  No chest pain or pressure at this time.   Plan: ASA.  Statin.  Metoprolol.  Ace.  lasix   RENAL MASS (9/22/2023)   Assessment: Noted on imaging, concern for RCC.  Discussed with Urology - defer to Onc.  Onc recommends biopsy (possibly lung lesion)   Plan: Will need follow up for biopsy or nephrectomy if indicated   ATRIAL FLUTTER, UNSPECIFIED (9/22/2023)   Assessment: Patient is at increased risk for CVA.  CHADS2vasc score is 4.  Patient is not on anticoagulation given risk of bleeding from renal mass.  Patient understands this risk   Plan: ASA.     ANEMIA (9/22/2023)   Assessment: Hgb low but stable, no evidence of bleeding   Plan: Monitor for bleeding   ABNL LIVER ENZYMES (9/23/2023)   Assessment: LFTs improved.  Suspect this was due to shock or CHF   Plan: monitor   MULTIPLE PULMONARY NODULES (9/25/2023)   Assessment: Noted on CT   Plan: Patient will require follow up     Primary Procedures:      Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  covid pneumonia, NSTEMI   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. CARDIOLOGY - INITIAL INPATIENT CONSULTATION. CARDIOLOGY - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code     Note Details  Author M.D. File Time 10/3/2023  1:17 PM Author Type Physician Status Signed Last Editor M.D. Specialty Critical Care Medicine Admit Date 9/22/2023  ED to Hosp-Admission (Discharged) on 9/22/2023  ED to Hosp-Admission (Discharged) on 9/22/2023   Detailed Report  Note shared with patient Hospital Problem List   ATRIAL FLUTTER, UNSPECIFIED  COVID-19 PNEUMONIA  ACUTE RESPIRATORY FAILURE  NONTRAUMATIC ACUTE KIDNEY INJURY  ELEVATED TROPONIN I  RENAL MASS  HYPONATREMIA Resolved  LACTIC ACIDOSIS, UNSPECIFIED Resolved  SHOCK, UNSPECIFIED Resolved  ANEMIA  ACUTE NON ST ELEVATION MI  ABNL LIVER ENZYMES  MULTIPLE PULMONARY NODULES  ACUTE CHF, UNSPECIFIED  ACUTE PULMONARY EDEMA Care Timeline  09/22   Admitted to ICU from ED 0827    Code 09/24   Transferred out of ICU 1046    Transferred to ICU 2100 09/27   Transferred out of ICU 1230 10/03   Discharged 1450  Discharge   Home or Self Care.   Discharge Instructions (Printed 10/3/2023) pt NOT vaccinated