Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Anticoagulation drug level below therapeutic, Aspiration, Asthenia, Bacterial test positive, Blood creatinine increased
Clinical narrative: Patient  is a 68 y.o. female, legally blind and chronically ill, originally presented 12/23/22 after being found confused and with hallucinations wandering around CVS, recently moved into new apartment (had been living with her mother).  Initially treated for UTI and AKI; then became hypoxic and found to be COVID-positive prompting transfer to the ICU for intubation 12/26. She was extubated 12/29 and transferred out of ICU 12/31/22. Found to have Mycobacterium mucogenicum on BAL prompting ID consult with no further inpatient workup.  Mental status was initially improved after ICU transfer to the floor, but then gradually worsened 1/5-1/7; with significant delirium, hypoxia and elevated WBC, suspicious for aspiration. Pt required re-intubation 1/7 per Pulm/CC team. Now extubated and back to the medical floor as of 1/11/23. Palliative consulted to assist with GOC, family currently wanting to continue current measures.  Patient is currently stable for discharge to facility   Assessment and Plan   Acute Hypoxic Respiratory Failure Recent Covid 19 MRSA PNA - Developed sore throat 12/24 after admission, noted to be positive COVID 12/25 - Initially on RA but decompensated 12/26, requiring NRB and then intubation, then had septic like picture briefly requiring pressors; extubated 12/29.  Also treated with antibiotics by ICU for possible concomitant pneumonia - Completed dexamethasone and remdesivir, removed from COVID isolation 1/5 - Bronch 12/26 with mycobacterium (see below) - Re-intubated on 1/7 upon transfer to ICU with concern for aspiration - Bronch Cultures w/ MRSA -Completed antibiotic therapy on January 14, currently afebrile hemodynamically stable with relatively stable white count - Urine cultures w/ Citrobacter - Extubated on 1/10; appears improved but remains very weak and would be high risk for repeat resp issues - Now weaned off  O2    Acute toxic/metabolic encephalopathy Hospital associated delirium - Likely has chronic cognitive impairment or progressive dementia not formally diagnosed; presented with severe hallucinations, AKI, UTI, and wandering around pharmacy - Behavioral evaluated early in hospitalization, felt her encephalopathy was due to AKI and UTI; head CT was non-acute - Mental status improved with treatment of acute illness but remains with cognitive delay and poor insight; ultimately will need formal neuropsych testing at discharge   AKI on CKD3 Hyperkalemia - In the setting of decreased PO intake and infection - Cr. 2.01 on admit, appears baseline is 1.4-1.7 -Kidney function improved. Cr was 1.10 on 1/15, now bounced back to 1.86 likely due to dehydration.  -start gentle IVF and monitor.  Encouraged oral fluid intake.  -Intermittent hyperkalemia with unclear etiology -Received Lokelma, potassium improving  We will continue to monitor  Dysphagia - Multifactorial in setting of debility, acute illness and intubations - Came out of ICU with NG and tube feeds -Speech therapy on board -Discussed with nutrition and bedside nursing -Patient with a regular NG tube causing throat irritation.  NG tube discontinued -Patient was reevaluated by speech therapy who recommended advancing diet.  Patient is likely blind so needs help with meals   Mycobacterium mucogenicum  - Noted in BAL 12/26 - Pt with cough, emphysema, adenopathy on CT chest; also nodular and ground glass opacities; QuantiFERON negative - ID consulted and signed off; Recommended AFB sputum culture, CBC and CMP about a week prior to her follow-up appointment, which will be in about 6 weeks - She will need a CT chest without contrast prior to ID follow-up with Dr.   Found on ground, possible fall in the hospital - Unwitnessed 1/1 PM, sounds like patient got frustrated and threw herself to the floor - CTH no significant change; fluid in R middle ear and mastoid air cells; CT C-spine without fractures  - Continue supportive care with PT/OT   Essential Thrombocytosis - Per history, previously supposed to be on Anagrelide 1 mg BID; appears not taking but still on COPC med rec; last visit noted 10/2021 - Plt elevated with this history and acute illness, peak 987 on 1/2, slight downtrend to 600-700s - Might need to have hematology see at some point in the OP setting once recovers from this acute illness   Hypertension, essential - Had been holding antihypertensives when in ICU with pressors and soft bps - Added back on coreg 1/13/23 and monitor; will resume norvasc too - Monitor BP and adjust meds as needed    Vitamin D deficiency - Vitamin D level low at 14, appears chronically low, started supplementation   UTI, resolved - Noted early in admission - Initially urine culture with Providencia, Klebsiella, completed Rocephin, repeat UA 1/5 negative - UA and Cultures Positive for Citrobacter 1/7 - Treated with Cefepime    Anemia, chronic - Unclear etiology, likely CKD contributing - Baseline appears to be around 9.5-11; currently ~9 - Monitor PVD - s/p aorto-fem bypass 1999, with thrombectomy 2004 - Continue medical management; resumed plavix and Zetia and transitioned to Eliquis per CCM   History of CVA - Reports residual left sided weakness, not noted on exam - Occipital and parietal infarctions without significant carotid disease - Continue eliquis, resume statin at discharge   History of DVT - s/p MVA in 1996 in RLE - Was on coumadin on admission although had been subtherapuetic - Transitioned to Eliquis   COPD, without acute exacerbation - Per history, no exacerbation - Continue as needed Duonebs   History of seizures - Per history - Previously on keppra but no longer taking AEDs   Legally blind - Secondary to MVA in 1996   History of chronic hepatitis C - Recommend outpatient f/u with PCP