Patient is a 57 y.o. male with history as outlined below as well as pertinent history of focal segmental glomerulosclerosis (status post living donor renal transplant; on chronic immunosuppression with tacrolimus), coronary artery disease (status post CABG x2 on DAPT), anemia of chronic disease; admitted to the hospital on 1/7/2022 for COVID-19 infection, following presentation with typical symptoms.  Patient was transferred to larger hospital due to anticipated multiple specialist need - nephrology for possible dialysis and interventional radiology for possible IVC filter.  Please see discharge summary from today authored by RN for further details regarding hospital course. Admission Date: 1/7/2022 Discharge Date: 1/14/2022    He will be transferred to Rehab care.   DISCHARGE DIAGNOSES: 1. COVID-19 infection 2. RLE DVT 3. Massive right sided / psoas hematoma with hemorrhagic shock 4. Native left kidney masslike lesion (12cm) 5. AKI on CKD3 6. ESTD previously on hemodialysis now s/p LDKT 7. Tacrolimus toxicity, resolved 8. Sepsis (presumably ruled out with sepsis parameters ultimately felt d/t hemorrhagic shock) 9. Immunosuppressed, febrile neutropenia 10. Acute metabolic encephalopathy 11. Diarrhea, resolved 12. Pulmonary vascular congestion 13. CAD s/p stent and CABGx2v, recent NSTEMI 14. PAD 15. T2DM 16. HTN 17. Obesity s/p gastric bypass surgery   ASSESSMENT/PLAN COVID-19 infection Suspected to be likely the etiology of his presenting symptoms. Fully vaccinated and boosted. Symptom onset 12/30, tested positive at home 12/31 (known exposure over Christmas).   - Currently stable on room air, continue pulmonary monitor  - Continue dexamethasone 6mg BID (in place of PTA prednisone 10mg daily)  - Not a candidate for tocilizumab or baricitinib d/t not having high flow O2 needs - Trend inflammatory markers being trended   RLE DVT D-dimer 1.62. Venous US showed partially occlusive thrombus on the right extending from the proximal femoral vein to the posterior tibial vein.  Patient is treated with IV heparin infusion (PTA aspirin 81 mg continued, Plavix held).  Heparin discontinued on 1/13 due to hemorrhagic shock see below. - Now holding PTA ASA 81mg and PTA Plavix - No longer a candidate for anticoagulation  - Transferred to larger hospital for possible IVC filter placement by interventional radiology; will consult   Hemorrhagic shock d/t massive right psoas muscle/right abdomen hematoma with acute blood loss anemia on anemia of chronic disease: -- Patient was anemic on presentation, suspected secondary to tacrolimus use. Subsequently developed severe right-sided back pain on 1/14 and worsening anemia (hemoglobin 5.5). Clinical evaluation showed massive multiloculated hematoma in the right side of the abdomen involving the right psoas muscle with large components extending into the right lateral abdomen and right midabdomen. -- CT angio done without evidence of active hemorrhage. Briefly required pressors (Levophed and vasopressin) until resuscitated with blood products. Hemodynamics have improved and are now stable.  - Continue to hold all forms of anticoagulation and antiplatelet - Type and cross - Monitor hemoglobin - Transfuse for hemoglobin less than 7   AKI on CKD3 Baseline Cr ~ 1.4-1.6. Creatinine trended up to 3.8 at time of transfer. Status post transplant and managed by transplant team. AKI initially thought to be secondary to prerenal azotemia in setting of dehydration; other factors considered include tacrolimus toxicity, worsened by hemorrhagic shock and contrast exposure. - Continue to coordinate care with kidney transplant team at hospital (it appears that they were engaged by hospital medicine service at hospital. - Nephrology consult service was part of his treatment team at Hospital; will consult to address need for dialysis if indicated - Holding azathioprine (per discharge summary recommended by transplant team), will need close coordination with this team to determine when to restart patient's transplant medications - Holding prednisone - currently replaced with dexamethasone  - Holding prophylactic Bactrim d/t AKI   Tacrolimus toxicity Appearance patient had supratherapeutic tacrolimus levels prior to arrival.  Again notes close coordination between hospitalist service and Transplant team, who recommended resuming tacrolimus after brief period of holding. - Continue tacrolimus at 3mg BID on 1/9 (down from his PTA 4mg BID dose) - Goal tacrolimus level is 4-6   Chronic immunosuppression Neutropenic fever Neutropenia thought to be secondary to tacrolimus toxicity.  Patient had febrile episodes which was initially thought to be from COVID but with persistent fever, immunosuppression and neutropenia, patient was empirically treated under infectious disease consult service guidance. BCx2 NGTD, UA/UC negative.  Completed antibiotic course on 1/14. - Monitor fever curve - Consult ID (consult service was part of the treatment team)   Acute metabolic encephalopathy Vertigo  Occurred on 1/10/2022 with associated nausea and vomiting. Stat head CT negative.  Waxing and waning with episodes of somnolence; wonder if component of ICU delirium.  - Repeat head CT to ensure no ICH   Diarrhea, improving Suspected to be multifactorial, secondary to COVID-19 infection tacrolimus toxicity. C.diff negative.   - Continue probiotic - Consider testing for enteric pathogens as this was not performed at the hospital  Pulmonary vascular congestion Noted on CXR on admission to the hospital.  Held off on aggressive diuresis due to AKI.  Recent echo at medical center therefore not repeated at Hospital. - Continue cardiopulmonary monitor - Patient closely being followed by pulmonology consult service over at Hospital; and accepted this patient to larger hospital; will consult   CAD s/p stent and CABGx2v, recent NSTEMI PAD On ASA and Plavix PT. Recent NSTEMI 1/3/22 in setting of Covid, no intervention. Trops negative. S/p endarterectomy.  Complications from anticoagulation and antiplatelets as outlined above. - ASA and Plavix being held as outlined above   HTN: - Restart PTA carvedilol, clonidine, minoxidil, hydralazine  which were held prior to transfer as a result of hemorrhagic shock - Losartan was held since admission d/t AKI; continue to hold - Hydralazine IV as needed for SBP greater than 170   HLD - PTA atorvastatin   OSA - Nocturnal CPAP   T2DM A1c 9.2%.  - PTA metformin on hold - Continue SSI, QID glucose checks - Monitor for hypoglycemia and treat as clinically indicated (as needed medications ordered)   GERD PTA Pepcid and Nexium - PPI IV ordered   Obesity S/p gastric bypass surgery. No acute concerns at this time.     FEN/GI: None/Replete PRN/Enteral  VTE PPX: Hold Home Medication List Reconciliation: Completed Access: PIV Code Status: Full Disposition: Anticipate likely greater than 2 midnights. PROGRESS NOTE 1/17/2021 Patient received additional unit of blood at normal hospital. IVC filter placed on January 15. Patient had acute metabolic encephalopathy due to multiple medical illnesses including suspected infectious process, COVID, he was able to be weaned off of oxygen however.   January 17: Hemoglobin increasing up to 8.9 from 8.3.  Sodium up to 147, creatinine down to 2.4 from 3.1.  Patient continues to be encephalopathic, oxygen saturation is 100% on room air and all vital signs are stable however.  Temperature is normal.  Net volume status is -16 L.  Patient has had inability to take oral intake for approximately 4 days, has missed all oral medication during this time, speech pathology is indicated that he is able to swallow, will encourage oral intake and oral medications immediately. Will direct nursing staff to give medications, otherwise need enteral access immediately.     PLAN   Suspected COVID-pneumonia Chronic immunosuppression Neutropenic fever Acute metabolic encephalopathy   -Infectious disease consulted -Received vancomycin, cefepime, Flagyl, antifungal, all discontinued -Dexamethasone 6 mg twice daily, home prednisone dose is 10 mg daily     Right lower extremity DVT status post IVC filter Hemorrhagic shock due to retroperitoneal bleed, abdomen hematoma, right psoas muscle hematoma Hypernatremia Acute renal failure Chronic renal failure stage III History of live donor kidney transplant On chronic tacrolimus, tacrolimus toxicity   -Nephrology consulted -Lasix drip per nephrology -Hold chemical anticoagulation, reassess daily -Hold azathioprine -Continue tacrolimus with lower than home dose -Goal tacrolimus level is 4-6 -Hemoglobin every 6 hours -Daily CBC       Chronic coronary disease, peripheral artery disease Chronic hypertension, hyperlipidemia Chronic obstructive apnea Obesity Chronic GERD Chronic type 2 diabetes with acute hyperglycemia, A1c 9.2 In the hospital diabetes management will be according to the guidelines with goal blood sugar 140-180 generally.    -Continue home long-acting insulin:  -Insulin may be ordered using basal, prandial, and correction doses based on this patient's previous insulin needs and/or weight -Sliding scale insulin available for now -Carbohydrate controlled diet -Hold metformin -IV PPI, transition to oral when appropriate -CPAP nightly when able -Continue home statin -Hold home aspirin and Plavix in the setting of hemorrhage, reassess daily -Holding losartan -Continue home carvedilol, clonidine, minoxidil, hydralazine