Age: 83.0
Sex: F
Vaccine: COVID19-2
Symptoms: Ammonia normal, Anticonvulsant drug level therapeutic, Atelectasis, Blood sodium normal, Blood thyroid stimulating hormone normal
Clinical narrative: Patient is an 84 y.o. female past medical history of inoperable meningioma, seizure disorder who presented on 2/7 with sudden onset of confusion, inability to follow commands in the setting of COVID-19.  Her symptoms persisted and she was transferred to alternate location on 2/10/2023.  Her symptoms have improved with supportive care throughout her hospital course.   Acute encephalopathy, resolved -Etiology remains grossly unclear.  Highest clinical suspicion at this point was either seizure activity versus metabolic encephalopathy in the setting of COVID-19 infection. -Intracranial imaging as per below -Continuous EEG without evidence of epileptiform activity.  UA, TSH/free T4 and ammonia unremarkable.  Levetiracetam level therapeutic. -Neurology followed and signed off 2/13.  Behavioral medicine also followed during admission.  -Continue dose adjusted Seroquel 75 mg nightly.  Continue Keppra as per below as well as ongoing PT/OT   Epilepsy -Follows with Dr., diagnosed 2018.  Epileptogenic focus thought to be due to known meningioma -Home Keppra increased to 750 mg twice daily per neurology recommendations.  Patient will follow-up with Dr. upon discharge   Meningioma -Known meningioma with sellar extension, poor surgical candidacy. Follows with Dr.  -MRI this admission again demonstrates large extra-axial meningioma unchanged from 5/2022 study -Neurology also recommend outpatient neuro-oncology referral which was placed prior to discharge    Abnormal MRI brain Incidental CVA  -MRI brain: Extra-axial mass consistent with meningioma measuring up to 5.4 cm in size stable from 05/2022 study.  Small focus of diffusion restriction in hippocampus on the left consistent with very small acute/subacute infarct.  Small focus of acute/subacute infarction with diffusion restriction on the right parietal lobe.  Nonspecific hyperintense signal in the posterior medial aspect of the thalamus on the right. -Neurology followed and signed off.  Recommend continuing ASA 81 mg, statin and 30-day cardiac event monitor with follow up in stroke prevention clinic. Defer interval MR brain regarding R thalamic lesion to neurology discretion.   COVID-19 Presented with: Altered mental status, sore throat, fever up to 102.4 F -Symptom onset: 2/6/23 -Positive COVID-19: 2/7/23 at Hospital -Vaccination status: Vaccinated x2 -CXR outlying hospital showed LLL atelectasis -Remained on room air throughout hospitalization, did not require any intervention L shin wound  Mild cellulitis -Significant skin tear of her L anterior shin. Unclear when she suffered this injury -Now with mild surround erythema and trace induration. No purulence noted but interrupted granulation tissue noted.  -Out of abundance of caution favor competing 5d course of Keflex 500 mg QID.    Essential hypertension -Coreg dose increased to 12.5 mg BID inpatient, continue on discharge   Central hypothyroidism -Continue home levothyroxine   Secondary adrenal insufficiency Per history. Hemodynamically stable. Patient given IV steroids at outlying hospital prior to transfer -Chronic prednisone 5 mg daily continued. Continue follow up with endocrinology Doctor   SIADH Per history -Na+ wnl this admission  -Continue salt tabs 1 g twice daily as per home regimen.  Monitor sodium levels