Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Liver function test increased, SARS-CoV-2 test positive, Seizure, Sleep terror, Subdural haematoma
Clinical narrative: Discharge Summary   Date of Admission:  11/18/2023    Date of Discharge:  Addendum: 11/24/2023     Primary Care Physician:  DO   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 10/22/2023 to 11/22/2023.       Issues to be Addressed in Follow-up: [] outpatient follow up with neurosurgery for repeat CT scan of brain for subdural hematoma [] outpatient follow up with psychiatry for depression and anxiety [] continue TXA - for 10 - 12 weeks (per Neurosurgery recommendation) [] Continue Keppra indefinitely (per Neurology recommendation) [] started lexapro 2.5mg daily (per psychiatry recommendation)   Reason for Hospital Admission (Admitting Diagnosis):  seizure, SDH    HPI on admission:  History of Present Illness: 74 y/o with PMH of HTN, HYPERLIPIDEMIA, GERD, CKD, obesity, gout OSA, SDH (discharged 11/14, no intervention) presented today after having episode of altered mentation (staring off into space).  Brought to ED, intubated for airway protection. Loaded with Keppra.  Head CT did not show significant worsening of SDH, in fact slightly less shift.  Also found to be COVID positive.  Neurosurgery accepted patient for ICU admission.       Hospital Course: Patient is a 74 Y  male with history of  HTN, HLD, GERD, CKD, Obesity, Gout, OSA, SDH (recently discharged for acute on chronic SHD on 11/14 with no intervention needed, presented to outside hospital for AMS, found to have AMS ans seizure, loaded with keppra, intubated and transferred to ICU for neurosurgical evaluation. Found to have slightly less shift of the SDH but also found to have COVID positive.  Neurosurgery consulted in the ICU and recommended continuing TXA. Extubated in ICU on 11/19.  Both Decadron and Remdesivir were stopped in ICU on 11/19. Discussed with neurosurgery, recommended continuation of TXA for 10-12 weeks. Discussed with neurology, recommended continuation of Keppra indefinitely with close follow up with neurology. Discussed with psychiatry, recommended initiation of Lexapro 2.5mg daily.   BP 120/63  | Pulse 66  | Temp 97.9 °F (36.6 °C)  | Resp 18  | Ht 5' 7.75"  | Wt 96.3 kg (212 lb 4.9 oz)  | SpO2 92%  | BMI 32.52 kg/m²  Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is not ill-appearing or toxic-appearing.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal. No congestion.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear. No oropharyngeal exudate.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.  Musculoskeletal:        General: No swelling. Normal range of motion.     Cervical back: Normal range of motion and neck supple. No rigidity.  Skin:    General: Skin is warm and dry.     Coloration: Skin is not jaundiced.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.     Cranial Nerves: No cranial nerve deficit.     Sensory: No sensory deficit.     Motor: No weakness.  Psychiatric:        Mood and Affect: Mood is depressed. (but improved)              Hospital Course By Problem: Patient Active Hospital Problem List:   1. Traumatic SDH (11/15/2023) ? Continue TXA ? CT head: Frontal SDH slightly decreased ? Outpt f/u with neurosurg as planned 2. Seizures, Generalized, Unspecified Type (11/18/2023) ? Keppra ? Neurology f/u for duration 3. Acute Respiratory Failure (11/18/2023) - resolved ? Post-seizure ? Tolerated extubation 11/19 4. COVID-19 Disease (11/18/2023) ? Not in respiratory distress ? Afebrile, no leukocytosis ? Regular COVID-19 vaccinations, pending update ? Minimal symptoms, improving LFTs ? Not a Remdesivir candidate ? Discontinue decadron - per ICU 5. HTN (Hypertension) (2/18/2015) ? Home atenolol 100mg initiated 6. Hypercholesterolemia (2/18/2015) ? Elevated LFTs, hold statin 7. Adult Obstructive Sleep Apnea, Moderate (2/10/2016) ? CPAP Qhs 8. Severe Obesity Equivalent (BMI 35-39.9 w/ Co-Morbidity) (3/23/2018) ? Noted 9. CKD Stage 3A (GFR 45-59) (6/23/2021) ? Noted 10.  Depression  ? Psychiatry consulted ? Addendum: discussed with psychiatry: recommended Lexapro 2.5mg Daily - ordered   Complications:  None   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) SEIZURES, GENERALIZED, UNSPECIFIED TYPE   ? ACUTE RESPIRATORY FAILURE   ? COVID-19 DISEASE   ? TRAUMATIC SUBDURAL HEMATOMA   ? CKD STAGE 3A (GFR 45-59)   ? SEVERE OBESITY EQUIVALENT (BMI 35-39.9 W CO-MORBIDITY)   ? ADULT OBSTRUCTIVE SLEEP APNEA, MODERATE       2-9-16: MODERATE severity OSA on Watch-PAT study with pAHI=19.9, low SpO2=89% (203lbs)  Reported hx sleep terrors   ? HYPERCHOLESTEROLEMIA   ? HTN (HYPERTENSION)     Resolved Hospital Problems No resolved problems to display.     Primary Procedures:  none      Secondary Procedures: None   Consults:  ICU Neurosurgery    Condition on Discharge:  Stable    Code Status at Time of Discharge: Full Code   Smoker: No.     Discharge Disposition:  Home   Discharge Medications: Medications, instructions, follow up information: See patient instructions (or SNF Admission orders if applicable).    Future Appointments    Appointment Date & Time Visit Type Provider Department/Facility   Nov 27, 2023 8:10 AM Telephone Visit (D.O.) ADULT & FAMILY MEDICINE   Dec 26, 2023 10:30 AM CT Scan HOSP CT 2 CT SCAN    Dec 28, 2023 5:30 PM Telephone Visit (P.A.-C) NEUROSURGERY           MD   11/21/2023  Note Details  Author (M.D.) File Time 11/24/2023  9:27 AM Author Type Physician Status Addendum Last Editor (M.D.) Specialty Hospital Medicine  Admit Date 11/18/2023  Admission (Discharged) on 11/18/2023  Admission (Discharged) on 11/18/2023   Revision History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   SEIZURES, GENERALIZED, UNSPECIFIED TYPE  HTN (HYPERTENSION)  HYPERCHOLESTEROLEMIA  SEVERE OBESITY EQUIVALENT (BMI 35-39.9 W CO-MORBIDITY)  CKD STAGE 3A (GFR 45-59)  ADULT OBSTRUCTIVE SLEEP APNEA, MODERATE  TRAUMATIC SUBDURAL HEMATOMA  ACUTE RESPIRATORY FAILURE  COVID-19 DISEASE Care Timeline  11/18   Admitted to ICU 2248 11/19   Transferred out of ICU 1912 11/24   Discharged 1400  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 11/24/2023) Medication List at Discharge   allopurinol 300 mg Oral DAILY AFTER A MEAL  atenolol 100 mg Oral DAILY  atorvastatin calcium 80 mg Oral DAILY, for cholesterol  escitalopram oxalate 2.5 mg Oral DAILY  ketotifen fumarate 0.025 % (0.035 %) 1 Drop Both eyes 2 TIMES A DAY  levetiracetam 1,000 mg Oral 2 TIMES A DAY  multivitamin 1 tab daily  tranexamic acid 1,300 mg Oral DAILY, To help subdural hematoma resolve  triamcinolone acetonide 55 mcg Use 2 sprays in each nostril daily. Reduce to 1 spray in each nostril daily when allergy symptoms improve