Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Cerebral small vessel ischaemic disease, Chest X-ray abnormal, Computerised tomogram head abnormal, Culture urine positive, Electroencephalogram normal
Clinical narrative: DISCHARGED- 4 DAYS The patient is a 77-year-old female with past medical history significant for diabetes mellitus, hyperlipidemia, hypertension, coronary artery disease and CVA who presented to the emergency department with altered mental status of 2 days duration. The patient was also noted to have decreased oral intake and vomiting. In the emergency department, the patient was oriented x2. CT head showed a 3 mm right frontoparietal convexity hyperattenuating subdural hematoma versus parenchymal thickening. CT findings were discussed with Neurosurgery and they felt that this is most likely hygroma. The patient was admitted for further evaluation and management of her altered mental status.  Her altered mental status was most likely secondary to toxic metabolic encephalopathy and baseline cognitive impairment. The patient was found to have urinary tract infection.  She was given IV ceftriaxone for urinary tract infection.  Urine culture was positive for Klebsiella pneumonia.  Neurology was consulted for further evaluation and management of her altered mental status. They recommended EEG. EEG was negative for seizures.  They also recommended brain MRI. Brain MRI showed no acute intracranial abnormality. Diffuse pachymeningeal thickening is again present though is moderately decreased since 4/10/2021. Mild chronic small vessel white matter ischemic change and remote tiny right cerebellar infarction. The patient will need formal neurocognitive evaluation 3 months.   The patient was found to have acute kidney injury.  On the day of admission, her creatinine was 1.5. Her acute kidney injury was most likely related to poor oral intake, vomiting and benazepril use. Benazepril was held. The patient was given IV fluids and with IV fluids her acute kidney injury has resolved. Lipase was elevated at 267. The patient did not have any nausea, vomiting or abdominal pain in the hospital.  Her liver enzymes have  been normal as well. She did tolerate general diet. The patient was found to have COVID 19 infection.  Chest x-ray showed patchy bibasilar opacities. During this hospitalization, the patient was not hypoxic and she was not given remdesivir or steroids.   During this hospitalization, the patient was found to have hypokalemia, hypomagnesemia, hypocalcemia and hypophosphatemia.  She was given potassium, magnesium, calcium and phosphorous supplements.   The patient was seen by PT/OT and they recommended the patient can be discharged home with home health care.  The patient will need to have 24/7 supervision at home.  This was discussed with her granddaughters and her granddaughters will provide home supervision and assistance along with home healthcare.   On the day of discharge, the patient denied any chest pain or shortness of breath.  No fever or chills.  No nausea, vomiting or abdominal pain.  No lightheadedness or dizziness.  Her vital signs have been stable.  She was tolerating diet.  IV ceftriaxone was stopped and prescription for cefdinir was sent to the pharmacy.  The patient will need to complete 7 days of antibiotic treatment for urinary tract infection.  The patient should have a follow-up BMP magnesium and phosphorus on 02/07/2022.  I have called her PCP's office and her PCP will order labs.  The patient was discharged home in stable medical condition.