Age: 68.0
Sex: F
Vaccine: COVID19-2
Symptoms: Computerised tomogram thorax normal, Condition aggravated, Confusional state, Culture urine, Diplopia
Clinical narrative: Patient is a 69 y.o. female hx of COPD, lung cancer s/p L sided pneumonectomy who presented from home on 9/5/2023 with weakness found to be hypoxic with COVID 19. Hospital course complicated by progressive focal weakness, diplopia, with concerns for possible neuromuscular etiology; neurology evaluated. Will transfer to Riverside for further neurological evaluation. Also currently undergoing septic work up.          Assessment and Plan   Acute on chronic respiratory failure with hypoxia COPD Exacerbation COVID 19  - Presented with: Dyspnea, hypoxia and weakness  - Symptom onset: 9/2/23 - Positive COVID-19: hospital 9/5/23 - CTPE on admission negative for PE - Oxygen status: Baseline PRN oxygen, presented on face mask weaned to 2-3L NC  - Decadron: Yes. Expected end date 9/14/23 - Remdesivir: Yes. Expected end date 9/9/23- completed prior to transfer - DVT prophylaxis:Lovenox - Serial COVID labs ordered: No - Case Management/Social Services consulted: Yes - Continue home inhaler regimen with scheduled albuterol QID Progressive weakness  Diplopia  - possible underlying neuromuscular disorder or possible exacerbation of chronic complaints with covid and possible UTI - though some concerning exam findings  -pt with baseline right foot drop, chronic history of dysphonia (follows with ENT) and some chronic left upper ext numbness  - in context of above; pt has stated she has new weakness in left leg since discharge from hospitalization around mid 8/2023 (pt was there with small bowel obstruction; s/p surgical intervention)  - pt normally does not use walking device though started using a walker several days prior to admission - over course of hospitalization at hospital this admission; pt with notable increased left lower extremity weakness and increased left upper ext weakness compared to right; also with new complaints of diplopia; mild ptosis b/l and weakness neck flexion; NIF around -20  to -25  - also intermittent complaints low back pain with left radicular symptoms with pain and paresthesias left lower ext  - MRI brain unremarkable; MRI cervical, thoracic and lumbar spine was overall unremarkable; shows herniated disc L4-L5 with narrowing lateral recesses on left; no central stenosis - this is similar to MRI in 6/2023 - neurology evaluated on 9/9 - concerns given progressive weakness; diplopia; b/l ptosis and neck flexion weakness  - considering myasthenia gravis, vs LEMS or AIDP vs other  - NIF's mildly low around - 20 to -25;  unable to obtain vital capacities at hospital given covid status per respiratory  - consideration given for IVIG though with some risk given hypercoagulable state with covid and cancer; no active clot though; unclear if underlying bacterial infection at this time  - per neurology; will hold on IVIG for now; preferred PLEX if needed though given pt's stability ideally planning for EMG evaluation; myasthenia gravis panel pending and IgA level pending; will need neurology consult. Updated on call neurologist about admission.    Bacteremia  - unclear if contamination or true infection  - blood cultures from 9/7 showing coag neg staph - only one blood culture was drawn (not sure why two were not collected) - repeated blood cx's 9/8 and started on vancomycin after repeat cultures were drawn - pt afebrile though weak with hypoglycemia requiring dextrose gtt and mild hypothermia overnight; transient hypotension that resolved  - cont vancomycin; IVF's, f/u repeat blood cx's  - pt also started on empiric zosyn with concerns for developing sepsis overnight  - noted TTE on 7/25/23 showed small linear mobile mass in RA of uncertain etiology; no valvular involvement; appears pt was to have cardiac MRI to further evaluate and did not have done yet; if repeat cx's positive then will plan for TTE and ID consult. Hypoglycemia - probably due to poor oral intake with underlying covid; evaluating for bacterial infection as well with above --with still some low/normal glucose levels despite dextrose in IVF's - infectious work up as above; - consider am cortisol level though current steroids may interfere with interpretation.  - cont D5W infusion  - monitor    Urinary retention  - noted overnight from 9/8 - 9/9  - possible UTI contributing to above - UA only with rare bacteria though unfortunately urine studies were not able to be collected prior to antibiotics  - consider at least 5 days empiric treatment for possible UTI that could be masked in context of above as this could also contribute to some of her symptoms  - cont foley catheter for now and voiding trial later    Metabolic encephalopathy  - pt with mild confusion; overall appropriate in conversation on exam; pt's husband noted some increased confusion at bedside  - suspect due to covid 19; possible bacterial infection as well - currently ruling out; also hypoglycemia and oxycodone ; also working up for neuromuscular disease  - MRI brain negative for acute process  - no known hx of myasthenia gravis or other neurodegenerative disease; follows with neurologist for orthostatic hypotension; no dysphagia  - cont dextrose in IVF's, reduce oxycodone; cont as above; urine cx pending though collected after antibiotics.  - monitor closely    Abdominal pain  Nausea  -  suspected nausea and intermittent vomiting due to COVID 19; pt with poor oral intake  - also urinary retention overnight  -  abd pain mostly RLQ -  abd soft, on exam; tender to palpation  - KUB on 9/7 with non specific haziness of abdomen - uncertain significance  - given recent surgery for small bowel obstruction, CT abd/pelvis was done and unremarkable - monitor; cont zosyn for empiric coverage for UTI in context of acute illness above.