Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Escherichia urinary tract infection, Fall, Gastrointestinal tube insertion, Gastrostomy, Hyperammonaemia
Clinical narrative: Hospital Course:    Patient is a 62 y.o. female patient of MD with that presented with weakness, falls, n/v   Discharge Diagnoses: 1. COVID-19 (resolved) -Date of onset of symptoms: 10/19/22 -Symptoms present on admission: Hypoxemia/ Cough -Date of covid positive test:  10/21/22 -Vaccination status:  J&J x1  -Imaging:  CXR- negative for pneumonia/pneumothorax/ pleural effusion  -Oxygen requirements on admission:   BIPAP -Current oxygen requirements: RA, 2L NC at night -Baseline Oxygen requirements: RA, 2L NC at night -Medical therapy: decadron, remdesivir (completed) -Consultants following:  Critical care/pulmonology  -Anticipated special isolation end date: 10 days from dx.   2. Chronic hypoxemic and hypercarbic respiratory failure - on 2L baseline at home. - Continue IS/PEP and monitoring. - Repeat VBG to evaluate C02 level   3. COPD exacerbation, Heavy Tobacco use  - Currently with rhonchi/wheezes. Completed decadron therapy - Continue with nebulizer treatments.  - At risk for aspiration. -Has tube feeding ongoing via DobbHoff   4. Acute encephalopathy, change in mentation - Secondary to infection. -Also with several medication changes this hospital stay with history of seizures and refused continuous EEG. I think postictal state is very likely contributing with ongoing breath through seizures as depakote was discontinued, as well as her benzodiazepines. PA discussed with palliative team. Consider xanax after initiation of trial of haldol for recurrent nausea and vomiting. Oxycodone slowly added on today. Will start with BID dosing. -Speech following   5. Seizure disorder/epilepsy - Refused continuous EEG. High suspicion for ongoing break through seizures. Very similar to prior hospitalizations. - Neurology followed. Vimpat 75mg BID. - Depakote dc due to hyperammonemia    6. Hypertensive heart disease - Continue to monitor. On sodium chloride tablets and may need an adjustment. -Nephrology following. Recommended continuing salt tablets.  7. Hyperammonemia - Resolved currently. Likely 2/2 to depakote.   8. Chronic pain disorder, Lumbar radiculopathy -Was on oxycodone at home. Starting low dose today (11/4) - Questionable withdrawal syndrome contributing to symptoms as medications discontinued all at same time.   9. Hyponatremia - Sodium q 6 hours. -Nephrology following - Avoid rapid correction.  -Continue salt tabs -121-134 over last 24 hrs - baseline neuro status noted on exam -Foley for strict I/Os -Cortisol level normal.   10. Nausea and Vomiting - Multiple differential: gastroparesis/ medication adverse SE/ withdrawal/ cyclical vomiting syndrome  -NG tube present. Need consideration of PEG again if agreeable. - Consulted gastroenterology- tentative plan for EGD 11/4 - may consider PEG placement, although pt has hx of noncompliance with PEG tubes in the past. She is not taking in adequate nutrition orally.    11. Acute UTI, E coli - Treated with Cipro. Completed regimen.   plan   Pt's vimpat has been increased to 75mg po bid via peg Depakote had been stopped due to high ammonia Seroquel stopped during hospitalization due to ams  Continue lactulose- check ammonia level at ecf  PEG inserted due to chronic nausea/vomiting, mupirocin for redness around peg site    Per nutrition   PEG tube placed on 11/4. TF re-started today   Current TF order: Isosource HN at 45 mL/hr. Will provide 1080 mL formula, 1296 kcals and 58 g Prot. 875 mL free water. Omit water flush d/t hyponatremia.