Age: 89.0
Sex: M
Vaccine: COVID19-2, FLUA4
Symptoms: Chest X-ray abnormal, Computerised tomogram head abnormal, Culture urine positive, Delirium, Dysarthria
Clinical narrative: BRIEF OVERVIEW: Admission Date: 7/17/2023 Discharge Date: 7/27/2023 Discharge Disposition:  skilled nursing facility   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Bradycardia [R00.1] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 90 y.o. male with PMHx in for AFib on Eliquis, coronary artery disease status post PCI, history of CVA, hypertension, hyperlipidemia, PAD, intermittent heart block, neurogenic bladder who was admitted to the hospital in the setting of COVID.    Patient initially presented to the emergency department on 07/17 for chief complaint of fatigue.  Patient was diagnosed with COVID on 7/15, tested in the context of his caregiver recently tested positive for COVID.  Patient noted to have low-grade fever A&O off at home.  Patient was prescribed 1 repair of year by his primary care doctor, and took 1 dose the morning of admission.    On presentation to the emergency department, patient noted to have temperature of 37.3° C, heart rate of 46, RR of 16, blood pressure 129/49, saturating 95% on room air.  EKG obtained notable for sinus Brady with first-degree block.  Chest x-ray obtained, which showed mild patchy right lung base infiltrates, mild cardiomegaly.  Emergency department did reach out to Cardiology, who did not feel as if patient required emergent pacemaker placement.  Patient did desaturate to 87% with ambulation, and was subsequently admitted to the hospitalist service in stable condition.   On admission to the hospital, patient noted to have intermittent delirium.  Patient initially with Foley catheter in as patient straight caths at home secondary to neurogenic bladder.  Patient noted to attempts to remove Foley catheter, was briefly in restraints.  Foley catheter and strands were subsequently discontinued, and patient continue to straight cath throughout admission.  Patient not noted to have any episodes of hypoxia throughout admission, no indication for remdesivir or dexamethasone.     Patient was noted to have complete heart block on EKG 7/10, was being worked up for outpatient pacemaker placement prior to admission.  Did discuss case with electrophysiology, who noted that there are currently no plans for inpatient placement of PPM but will need outpatient follow-up.     PT/OT consulted, who recommended skilled nursing facility.  Per care manager, facility plans to accept after 10 day quarantine.   While awaiting placement, patient developed acute hyponatremia, suspected due to SIADH. Seen by Nephrology. He was started on salt tablets and fluid restriction with gradual improvement.    Patient also developed new onset facial droop, dysarthria. Neuro was consulted. He underwent imaging which showed CTP: critical hypoperfusion volume of 28 mL in the left occipital parietal region and a core infarct of 10 mL in the same area. Mismatch volume 18 mL, CTA: Occlusion right vertebral artery at its origin, R ICA stenosis 90%, L ICA stenosis 75%, stenosis of P2 segment.  Patient with severe ICA stenosis, will require follow up and monitoring. MRI Brain was unable to be obtained due to implanted spinal stimulator.  Repeat head CT was done 7/27 and showed no acute findings. Neurology recommended continuing statin and Eliquis. Etiology for left facial droop and encephalopathy remained undetermined.    Patient with history of neurogenic bladder requiring CISC. He was noted to have hematuria with stable hemoglobin. Urology was consulted who recommended renal US, which showed no explanation for hematuria. Urinalysis was concerning for infection despite patient without symptoms. Culture was obtained which grew E coli. Urology recommended a 7 day course of keflex.