Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Dehydration, Electrolyte imbalance, Fibrin D dimer increased, Food refusal, Glycosylated haemoglobin increased
Clinical narrative: HOSPITAL COURSE: The patient is a 61-year-old female with a history of intellectual disability and developmental delay, uncontrolled diabetes not on any medications with A1c 11.5, presenting to the hospital for weakness.   Hospital course:   In the emergency room the patient was found to be tachycardic and tachypneic with elevated WBC, dimer, sodium to 159, glucose to 742 with elevated creatinine and lactate.  Suspected HHS, started on insulin and dextrose.  Patient was found to be COVID-positive 1/11/2022.  Right middle lobe infiltrate seen on imaging, CT scan of the chest, started on antibiotics for suspected bacterial pneumonia.  Patient was not hypoxic.   Patient was initially admitted to the ICU on insulin drip, blood sugars quickly improved.  Patient did not have good oral intake throughout the early portion of her hospitalization and was resistant to taking oral intake despite return to her baseline level mental status.  Speech pathology consulted.  Electrolytes and renal function slowly returned back to normal on D5W drip.  Patient had elevated dimer but CT scan of the chest and lower extremity Doppler ultrasounds were negative for VTE.  Continued on standard dose DVT prophylaxis with enoxaparin.   By 1/17 she had continued stability and remained at her baseline mental status. She continued to deny food and PO intake. It is thought that her poor PO intake was behavioral with maybe some contribution from lack of taste 2/2 COVID.  SLP was unable to work w/ patient due to refusal of eating/drinking or participating with their assessment.  She also does not have cognitive capacity to participate in exam and explain why she is refusing to eat. This was discussed with her sisteer who is primary caregiver. She expressed pt likes specific foods and can refuse things if she doesn't want it.  Again thought her PO intake was behavioral. Due to this, the best plan for improving her PO intake was determined to be getting back home to a familiar setting with her sister and foods she likes.  Discussed this with her sister who was in agreement and excited to have her sister come home. Plans were for DC on 1/19 evening, however family called later in the evening and reported they could not provide support / cares until the morning as they were making arrangements. Pt DC on 1/20/22   For more detail, please see admission H&P.  Hospital course dictated by problem:     Suspected HHS Hypernatremia Hyperkalemia, hypokalemia Dehydration Acute Kidney Injury/Acute Renal Failure As above. Lytes normalized and AKI resolved.     Chronic type 2 diabetes with acute hyperglycemia, A1c 11.5 Poor oral intake As above, poor intake thought to be behavioral and best mgmt plan is to return home to familiar environment and foods she enjoys.  PTA on metformin 1000mg BID. Per family sugars are not as controlled as they would like but they have found a good balance with this as the patient does not tolerate insulin very well (injection). Per family pt has enough metformin at home and no refills needed.     COVID-19 without COVID-pneumonia Elevated dimer due to the above Suspected bacterial community-acquired pneumonia Suspect severe sepsis due to the above Leukocytosis -Finished 5-day course of ceftriaxone azithromycin -CTPA and lower extremity Doppler ultrasounds negative for VTE     Chronic developmental delay, intellectual disability Low T3 level -Outpatient follow-up for thyroid   DISCHARGE DIAGNOSES:  Principal Problem:   Hyperosmolar hyperglycemic state (HHS) (HCC) Active Problems:   Type 2 diabetes mellitus without complication, without long-term current use of insulin (HCC)   Developmental delay   COVID-19   Pneumonia, suspected bacterial