Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: Blood bicarbonate normal, Blood bilirubin normal, Blood chloride increased, Blood creatinine normal, Blood folate normal
Clinical narrative: Hospitalized (1.24.22 - still admitted currently); COVID-19 positive (1.14.22); Fully vaccinated -pfizer x2 1/31/22 General Medicine Progress note:  at 1/31/2022  3:54 PM I have personally interviewed and examined the patient on 1/30/2022. Management was discussed with PA. I agree with the documented findings and plan of care in his/her note.   Brief Exam:  General:  Alert, elderly male Cardio:  Regular rate and rhythm Pulm:  No respiratory distress, clear GI:  Soft, nontender Ext:  No lower extremity edema Neuro:  Oriented to person, states he is in GR, states he is at a LTC facility, he states the year is 2033   Brief history and medical decision making:  Patient is an 84-year-old male admitted with acute encephalopathy in the setting of mild cognitive impairment.  Initially thought to be secondary to urinary tract infection however urine culture negative.  No other infection identified.  Continue off antibiotics.  CT head negative.  Patient noted to have recent COVID-19 infection.  Chest x-ray findings likely secondary to COVID as procalcitonin is normal.  Neurology was consulted for patient's encephalopathy. MRI brain with chronic findings, no acute findings. Continue to maximize sleep/wake cycle and reorient frequently. PT/OT recommends 24 hour assist given cognitive deficits. Possible progression of dementia.  ASSESSMENT/PLAN: Acute encephalopathy in setting of mild cognitive impairment- improving - Suspect related to recent covid infection/underlying dementia  - CT head negative for acute intracranial abnormalities, stable mild chronic microvascular ischemic changes and volume loss, right paramedian suboccipital subcutaneous fat lipoma - MRI brain with and without contrast without acute findings; notes mild generalized atrophy with probable moderate chronic white matter small vessel ischemic disease - TSH normal, b12, folate wnl; UDS negative  - Neurology consulted; no further recommendation  - d/c neuro checks; reduce interruptions at night  - zyprexa 2.5 mg and melatonin 9 mg nightly  - out of restraints since morning of 1/30.    - SLP for cognitive eval->severe cognitive communication deficit  - pt will need neuropsych eval outpatient; wife updated  - has  paperwork naming wife; not activated  - PT now recommending 24 hour assist; family has coordinated for pt to go nursing home in their memory care unit; are hoping for bed available tomorrow; family will transport  Recent COVID-19 infection - Vaccinated 1/26/21 and 2/16/21 with Pfizer, not boosted - Onset symptoms: 1/13/22 - Positive test: 1/14/22 - Not hypoxic, no current treatment Mild transaminitis,improving  - Likely 2/2 recent COVID-19 infection - repeat improving this AM; should have recheck in 1 week  Bacteruria - originally thought UTI contributing to AMS however urine cx negative  - received x2 doses of rocephin; stopped 1/26 when cx negative - continue to monitor off abx   Essential hypertension - Continue amlodipine, lisinopril-hctz  BPH- Continue flomax Asthma- Continue home inhalers  DVT prophylaxis: - This patient is high risk per the VTE risk assessment tool, pharmacologic prophylaxis is indicated. lovenox subq has been ordered.   Dispo: Mentation remains confused, no changes. PT recommending home with assist. Family plans for transfer to Nursing Home Memory care unit tomorrow. Wife plans to arrange transport  OBJECTIVE: BP 132/71  | Pulse 61  | Temp 36.4 °C (Oral)  | Resp 22  | Wt 87.4 kg  | SpO2 97%  | BMI 26.86 kg/m²    Physical Exam Constitutional:      Appearance: He is not ill-appearing or diaphoretic.     Comments: Pleasantly confused   HENT:     Head: Normocephalic.     Nose: Nose normal.     Mouth/Throat:     Pharynx: Oropharynx is clear.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate.     Heart sounds: No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing or rhonchi.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Coloration: Skin is not jaundiced.  Neurological:     Mental Status: He is alert.     Comments: Oriented to person, place, not time or situation; moving all extremities; following commands   Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior is cooperative.        Cognition and Memory: Cognition is impaired. Memory is impaired.        Judgment: Judgment is impulsive.