Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Aortic stenosis, Blood lactic acid normal, COVID-19, Cardiac telemetry normal, Cerebrovascular accident
Clinical narrative: Admit date: 1/13/2024  Discharge date:  1/17/2024  Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: MD  Reason for Admission:  67-year-old female with history of embolic stroke, small-vessel cerebrovascular disease, cocaine abuse, nicotine abuse, cannabis abuse, uncontrolled hypertension, chronic kidney disease stage 4 and chronic diastolic heart failure with preserved ejection fraction in the setting of severe left ventricular hypertrophy presented with confusion and question of syncope after a ground level fall that was unwitnessed.  Patient was found by family and notably had a several-day history of cough, nausea and vomiting.  History was obtained by family due to patient's confusion and patient did not have much recollection of events preceding coming to the hospital.   Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  Patient was found to have sepsis with evidence of fever and tachycardia with leukocytosis with neutrophil predominance lymphopenia on admission.  Patient was notably positive for COVID-19.  Patient was initially thought to have possible urinary tract infection but had sterile pyuria on urinalysis with negative urine culture.  Patient received a 500 mL IV fluid bolus in the ER with no further fluids given with normal blood pressures and normal lactate.  Patient was initially given IV ceftriaxone with resolution of leukocytosis and fevers.  Prior provider felt presentation was likely due to a viral sepsis presumably due to COVID-19.  Because of patient's presentation with leukocytosis and neutrophil predominance I restarted IV ceftriaxone and added IV azithromycin to cover for sepsis due to community-acquired pneumonia.  Patient did not have any hypoxia so I deferred treatment of COVID-19 other than supportive care.  Patient's acute encephalopathy on admission was superimposed on likely vascular dementia with patient having history of multifocal CVA May 2023 as well as significant small-vessel cerebrovascular disease.  She had no evidence of acute pathology on head CT.  There was also some question of whether patient could have a concussion at home and whether cocaine and/or marijuana were contributing with her urine drug screen positive for both.  Patient's mental status improved throughout hospitalization and returned to her prior baseline according to family.  With respect to patient's possible syncopal episode at home.  Patient was monitored on cardiac telemetry and remained in normal sinus rhythm with no evidence of heart block or other malignant arrhythmias.  Echocardiogram showed mild aortic stenosis with severe LVH and grade 1 diastolic dysfunction with no evidence of structural heart disease which would make her susceptible to syncope.  Patient also had no evidence of orthostasis.  Per family patient had not been taking any medications for some time.  We restarted low-dose aspirin and high-intensity statin and restarted blood pressure medicines to optimize vascular risk factors and to control blood pressure in the setting of chronic heart failure with preserved EF.  Social work was consulted related to patient's polysubstance abuse.  Patient was noted to have iron-deficiency anemia but had no signs of active GI bleeding during hospitalization.  Of note, patient was discharged on oral cefdinir (renally dosed) and azithromycin to complete a 5 day course of azithromycin and total 7 day course of 3rd generation cephalosporin after missing day between day 2 and 3. Discharged to Home.