Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Hepatic enzyme, Hyperammonaemia, Hypercapnia, Hypernatraemia, Hypotension
Clinical narrative: Admit date: 1/17/2024  Discharge date:  02/05/2024  Admitting Physician: MD   Attending Physician at the Time of Discharge: MD  Primary Care Physician: MD Reason for Admission: Altered mental status, COVID positive  69-year-old female with a past medical history of coronary artery disease, chronic obstructive pulmonary disease with chronic respiratory failure on 3 L of oxygen at home, DM2, hypertension, hypothyroidism, cognitive impariment, severe OCD and anxiety being admitted with altered mental status, agitation, hallucinations, and significant anxiety.  Is a readmission in 4 days  Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  Neurology and psychiatric consultation  1/ 19 Periods of agitations, hallucinations paranoid feelings  1/21 had acute on chronic hypercarbic respiratory acidosis, started on BiPAP, continues to be agitated -could not get MRI of the brain due to extreme agitation 1/ 22Pulmonary consultation, stopped steroid on the recommendation of Pulmonary Service, as was felt that patient does not have chronic obstructive pulmonary disease exacerbation 1/ 23 Started certification process for transferred to Geri psych 1/ 24 Continues to refuse PO meds , Calmer  1/ 27 Had MRI of the brain and lumbar puncture under anesthesia 1/ 25 ABG showed compensated chronic respiratory acidosis 1/ 29 Patient is more calm, pleasant, off restraints, compliant with orally medications, wore CPAP overnight however follow-up ABG this morning shows inadequate CPAP last night with significant acute on chronic respiratory acidosis, will resume BiPAP at night 1/30 Consultation and follow-up by Pulmonary Medicine, goal is to get patient back on CPAP, which would allow us to transfer the patient to Geri psych unit Patient still refuses to take oral medications on occasions 1/ 30-pulmonary opinion  As a result, NIV therapy with VAPS-AE is recommended because of the ability of this mode to provide a targeted tidal volume an auto adjusted EPAP. VAPS-AE is only available in the Trilogy/Astral NIV.  This mode will maintain tidal volumes and better address partial to full obstruction for altered lung mechanics related to position. This increases the likelihood of comfort and adherence which will have a high impact on long-term outcomes.  For this reason BiPAP/BiPAPST/BiPAP-VAPS therapy has been ruled out.  Without NIV with VAPS-AE, the patient is likely to experience life-threatening exacerbations with respiratory failure causing frequent readmissions  1/30 Transferred to general floor out of PCU Was on BiPAP for short time last night Had chest pain, troponins are mildly elevated, insignificant delta PT/OT ordered, trying to encourage patient to drink lots of water, D5W infusion being stopped 2/2 PT recommending SNF  2/4 patient wants to go home Seen by palliative care service in consultation for GOC Patient and family would like her to be at home  Hyperammonia -started on lactulose, valproate level is therapeutic  Acute delirium/encephalopathy with hallucinations in context of cognitive disability, recent COVID, known severe OCD and anxiety- This has been progressing rapidly over a matter of months. FAmily is unable to care for her at home. Extensive workup including psychiatry consultation were recently undertaken without significant findings. Will pursue geri-psych placement for the patient.  - Check thiamine level -pending result - Psychiatry recommends against antipsychotics given prlonged QTc but perhaps consider ativan although BP has been low after administration, since then QTC has normalized 1/19 requested psychiatric consultation, appreciate psychiatric consultation and follow-up - appreciate neurology consultation, MRI of the brain could not be done due to agitation, initially which was later on done under anesthesia 1/27  - appreciate help from Psychiatry Service and follow-up 1/25, rather unremarkable some diffuse slowing Psychiatric symptoms are being managed with the help of BuSpar, Depakote and Haldol 2/2 has high ammonia level of 67, started on lactulose, will trend ammonia level, valproic acid level is therapeutic, liver enzymes are normal 2/3 ammonia level trending down 2/4 ammonia level is normal  COVID viral syndrome- Diagnosed on 1/13 with viral type symptoms. Nursing concerned she is hot but no fever documented or reported. With no fever or leukocytosis a pneumonia is unlikely. Monitor for improvement. Does not meet criteria for COVID treatment currently and  risk likely outweights the benefit of steroids or remddesivir.   Chronic hypercanpnea/hypercarbia with chronic respiratory failure- Pulmonology was consulted recently, and stated that with a normal pH on ABG and and a relatively stable CO2 on metabolic panel her symptoms are not likely due to this chronic hypercapnea. She remains on her home oxygen that she was discharged on 3 days ago. Will monitor metabolic panel and respiratory status.  1/21 significant acute on chronic respiratory acidosis with hypercarbemia, started on BiPAP Mild hyper natremia on 01/20, changed IV fluids NS to D5 half NS, steroids have been discontinued at the recommendation of Pulmonary Service  HFrEF- last echo 1/2 with EF 45-50%. No evidence of additional pulmonary compromise but congestion on imaging. Monitoring   Paroxysmal AFib-giving consideration for Eliquis as CHADVVASC score is 4, 1/29 had cardiology consultation, review of the EKG and telemetry readings by Cardiology, ruled out AFib, tremors related artifacts and frequent PVCs  Abnormal kidney function- improved   Coronary artery disease  Chronic obstructive pulmonary disease , with moderate pulmonary hypertension  1/19 worsening oxygen requirement, 1/19 CTA pulmonary artery negative for PE Continue with Laba, Lama  DM2 hypertension - Hold losartan and torsemide given low BP after ativan  Hypothyroidism-  recent thyroid studies normal.  1 / 24 - Hypernatremia - IVF changed to D5 W  1/22 had family meeting, explained to them about Geri psych transfer  Constitutional:  Obese, on 3 liters/minute of O2, needs BiPAP intermittently,  off wrist restraints, sitter present HENT:  Normocephalic, Atraumatic, Pupils Reactive, Normal oropharynx, Nose normal.  Cardiovascular:  Normal heart rate, Normal rhythm, No murmurs, No rubs, No gallops.  Respiratory:  Decreased breath sounds, No respiratory distress, No wheezing, No chest tenderness.  GI:  Bowel sounds normal, Soft, No tenderness, No masses, No pulsatile masses.  Extremities:  Intact distal pulses, No edema, No tenderness, No cyanosis, No clubbing.  Neurologic:  Alert & oriented x 3, , No focal deficits noted.  Tremors + Skin:  Warm and dry   Issues Requiring Follow Up: (Who, what, when, and how communicated?)  Patient to use NIV at night at home, which has been arranged Follow-up with Pulmonary Medicine Follow-up with outpatient mental health service Discharged to Home Health Services.