Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Red cell distribution width normal, Respiratory acidosis, SARS-CoV-2 test positive, Sepsis, Septic encephalopathy
Clinical narrative: Hospitalized (2.16.22 - 2.19.22); COVID-19 positive (2.16.22); fully vaccinated PLUS Booster - moderna x3 d/c summary:Discharge Summary   BRIEF OVERVIEW:  Admission Date: 2/16/2022 Discharge Date: Feb 19, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? Lab test positive for detection of COVID-19 virus 02/16/2022 Yes ? Stage 3b chronic kidney disease  02/16/2022 Yes ? Hypothyroidism 02/16/2022 Yes ? LBBB (left bundle branch block) 02/16/2022 Yes ? Pure hypercholesterolemia 07/11/2011 Yes ? Prostate cancer  07/11/2011 Yes ? Diabetes mellitus 07/11/2011 Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Sepsis  02/17/2022 02/19/2022 Unknown ? Sepsis with encephalopathy  02/16/2022 02/19/2022 Yes ? Sepsis with encephalopathy without septic shock    Discharge Disposition:  home or self care   Active Issues Requiring Follow-up:   Pending Labs    Order Current Status   Vitamin B1 Blood Level In process   Peripheral Blood Culture Preliminary result   Peripheral Blood Culture Preliminary result DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Severe sepsis [A41.9, R65.20] Sepsis with encephalopathy without septic shock, due to unspecified organism [A41.9, R65.20, G93.40]   HOSPITAL COURSE: Sepsis on admission resolved prior to discharge.There was no known etiology, chest xray and UA unremarkable. Blood cultures negative to date, hypotension on admission responded to fluids, however BP remained soft. Patient told us that his BP is chronically low at home ,he claims it is usually in the 80s systolic. However we started him on midodrine and BP has been in the low 100s.  He is asymptomatic for covid 19, he is not sob and has remained on room air. He has a mild cough and has been on iv zosyn and doxycycline for sepsis. He may be discharged on 5 more days of oral doxycycline for atypical pneumonia/bronchitis He was evaluated by PT/OT and will be discharged back home . He refused home care services INPATIENT PROCEDURES:   BP 111/66  | Pulse 57  | Temp 36.8 °C (Oral)  | Resp 18  | Ht 1.88 m  | Wt 87.3 kg  | SpO2 100%  | BMI 24.70 kg/m²    Physical Exam HEENT normocephalic atraumatic Neck supple Lungs with good air entry bilaterally normal respiratory effort Cardiovascular S1-S2 present no murmur Abdomen soft nontender nondistended no guarding no rigidity Extremities no calf tenderness no cyanosis no edema  2/16/22 H&P:  CHIEF COMPLAINT: Sepsis with encephalopathy  ASSESSMENT / PLAN: * Sepsis with encephalopathy Assessment & Plan -hypotension, fever, though source unclear -UA appears negative, no consolidation on CXR, denies wounds -Does have Covid, but not hypoxic; lactate negative -Mild respiratory acidosis with pH 7.30, pCO2 53 on presentation -ED reports he was nearly unresponsive on arrival; repeat tonight is 7.35/35, check in am -Give 2nd L of fluids, continue Zosyn, start LRD5@75 -Procal is 3.34; follow up blood cultures    Lab test positive for detection of COVID-19 virus Assessment & Plan -Screened positive; he's had nausea/vomiting/diarrhea x3 days -No hypoxia/cough, no infiltrates/opacities on CXR -Ferritin 388, CRP 64.4 -Dimer is 1430, typical for Covid, will follow; start BID Lovenox   Prostate cancer Assessment & Plan -He is s/p prostatectomy -He's had poor appetite x1yr and apparently has lost 80lbs -I'm unable to get further hx from pt/chart -May need pan-scans once recovered from acute illness -Check PSA   LBBB (left bundle branch block) Assessment & Plan -On EKG today, with RBBB as well -No EKG since 2011, which had no bundle pathology   Hypothyroidism Assessment & Plan -TSH today 1.39 -Continue home levothyroxine 50mcg    Stage 3b chronic kidney disease Assessment & Plan -Creatinine 1.56 from 1.43 in 2019; GFR 44 from 49 -CK normal   Diabetes mellitus  Assessment & Plan -He's on glipizide; no recent A1c's, check in am -Reportedly eating only bowl of cereal, a small snack and a microwave packaged meal daily -Check B12, thiamine, folate levels in am -Glucose is 72 on presentation; would expect it to elevate in stress setting -No insulin for now; D5 in fluids as well   Pure hypercholesterolemia Assessment & Plan -On gemfibrozil; hold for now in setting of AMS to reduce pill burden -Check lipid panel in am   HISTORY OF PRESENT ILLNESS: Patient is a 72 y.o. male who presents today with confusion and weakness. Hx mostly from chart and ED as pt able to give little hx. He's been vomiting/diarrhea for the past 3 days, and was reportedly just too tired to leave his chair, and has been incontinent as a result. EMS was called by his roommate.   In the ED, he was hypotensive to 70's, febrile to 103. He was given 1L of fluid pending Covid result, and blood pressures improved to 90's. He was given Zosyn. Labs showed normal lactate,  VBG with respiratory acidosis 7.35, PCO2 of 53; renal function similar to 2019 with negative CK.    Mild leukopenia 3.81, mild anemia Hgb 13.6. UA with some hyaline casts, but no sign of infection. He did test (+) for Covid, has been vaccinated. Inflammatory markers showed ferritin 388, CRP 64, dimer 1430. Blood cultures drawn. He requires admission for treatment of sepsis with AMS, unclear source.    He has other PMH of prostate cancer s/p prostatectomy, diabetes mellitus, hypothyroidism. As he is not fully oriented, and I cannot contact his roommate, I speak to his brother.    He tells me patient has lost about 80lbs in one year, and he's not sure if he meant to. Says his brother has lived alone most of his life, has rented out a room to a friend fallen on hard times. Says he doesn't drink, and he doesn't think he uses drugs either.   Patient Active Problem List Diagnosis ? Pure hypercholesterolemia ? Prostate cancer  ? Diabetes mellitus  ? Hyperlipidemia ? Pancreatitis ? BPPV (benign paroxysmal positional vertigo), unspecified laterality ? Weakness of both lower extremities ? Sepsis with encephalopathy  ? Lab test positive for detection of COVID-19 virus ? Stage 3b chronic kidney disease  ? Hypothyroidism ? LBBB (left bundle branch block OBJECTIVE: BP (!) 98/49  | Pulse 75  | Temp (!) 39 °C (Oral)  | Resp (!) 31  | Ht 1.829 m  | Wt 81.6 kg  | SpO2 92%  | BMI 24.41 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed and well-nourished. He is ill-appearing.     Comments: Drowsy but awakens to my entering and to name. During interview, dozes off easily and needs shaken to remind him of a questions.   HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are dry.  Eyes:     General: No scleral icterus.    Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Neck supple.     Right lower leg: No edema.     Left lower leg: Edema present.  Skin:    General: Skin is warm and dry.     Coloration: Skin is pale.  Neurological:     Comments: Oriented to self.  Psychiatric:        Mood and Affect: Mood and affect normal