Age: 93.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Hypothermia, Impaired self-care, Influenza A virus test negative, International normalised ratio normal, Klebsiella infection
Clinical narrative: Hospital course 2/20 in the ED CC: Pt has been treated for UTI with Cipro and now Doxycycline. Pt continues to have bacteria in Urine and is significantly weaker per son who she lives with. Did not want to get up today and has worsening chronic tremors. Son reports she usually talks but has not spoken since last night. Pt also reported to have not been eating or drinking well since yesterday and was unable to take medications this AM.    93-year-old female sent to the emergency department by family with concerns that she is delirious, not acting herself, nonverbal, not eating or drinking, getting weaker.  Her tremors, which are present at baseline, are getting worse over the course of the last week.  Over the course of the last 7 to 10 days the patient has been diagnosed with a UTI and treated with ciprofloxacin, had a repeat UA done and started on doxycycline of which she has taken 3 doses.  There is concerned that her UTI is worse.  Patient is essentially nonverbal and is not able to provide any history.   Problem list Thrombocytopenia ? no medications, no transfusions. Hematology consult 2/23 ? History obtained from chart and son.  Approximately 3 weeks ago patient was in her USOH and developed multiple UTIs requiring 2 separate antibiotic regimens (Cipro and doxycycline).  At around that time she received dose 1 of her COVID vaccine.  Subsequently, her mental status per her son deteriorated and on 2/20, she presented for confusion with hypothermia.   Since that time, she has been noted to have thrombocytopenia.  CBC on admission notable for PLT of 59.  Prior CBC was in 2016 and was normal. Assessment: probably ITP;  DIC and TTP ruled out   Sepsis ? unknown source, broad spectrum antibiotics  AMS/encephalopathy ? no medications.  Neurology consult 2/22 - The patient is a pleasant 93-year-old female who was functioning independently approximately 3-4 weeks.  She was caring for herself and managing her own checks. She received the COVID vaccine and days later started experiencing confusion and inability to care for herself.  She was found to have a UTI. She completed treatment with Ciprofloxacin.  Cultures initially grew Klebsiella and subsequently E.Coli.  She was placed on Doxycycline.  She never completed recovered from the UTI.  On 2/20/2021, the patient developed worsening confusion and severe hypothermia.  She was admitted to the hospital for Sepsis of unclear source at this time.  She was placed on Cefepime for broad coverage.  Since being admitted, she is more awake, conversing, but still quite confused.    Today, the patient appears confused.  She does not participate with the examiner.  She asked if she is going to spend all her life here. She is able to move her arms and legs spontaneously.    Assessment: Acute encephalopathy manifesting as delirium.  Multifactorial.  Due to poor recovery from recent UTI, neurotoxic effects of antibiotics, and dehydration and hypothermia related to sepsis.  She has no stroke and does not appear to have seizures.   Hypoglycemia ? dextrose  2/24: Patient unfortunately not improving.  Cognition has not improved.  She remains minimally reactive to verbal stimulation. Extensive work-up has not found any reversible cause to date.  Decline may be associated with recent UTI and its treatment, elements of depression and dementia.  Case reviewed with the patient's son.  Further discussions will be held with all of her available children later today.  We discussed the possibility of transition to comfort care given the poor medical prognosis.  2/25: Comfort care measures only per family?s wishes  2/26: Patient subsequently passed with sons at bedside.