Age: 90.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Diarrhoea, Dyspnoea, Electrocardiogram normal, Glycosylated haemoglobin normal, Hyperchloraemia
Clinical narrative: Upon arrival to the emergency department, patient was found to have acute hypoxemic respiratory failure.  Chest x-ray was concerning for mild left basilar infiltrate.  He was also noted to have leukocytosis, anemia, hypernatremia, hyperchloremia, uremia, and elevated troponin.  Renal function seems to be at baseline.   07/25/2021tested positive 7/28/2021 discharged 91-year-old male with past medical history of prostate cancer 30 years ago status post surgical removal, coronary artery disease, and stage 3 chronic kidney disease who is also a DNR presented to the emergency department with worsening weakness and confusion.  Patient is unable to provide any history himself.  Patient's daughter was contacted directly.  Per her reports, patient was his usual state of health until approximately few months ago when his wife died.  Patient has not been himself since then.  He was admitted approximately 1 month ago due to changes in mental status.  He was discharged and went to rehab facility.  Patient went home approximately 1.5 weeks ago and at that time, per the daughter's report, he was doing very well.  Patient was able to take care of himself for the most part.  Mental status was also intact.  After about 1-2 days, patient started having weakness, poor oral intake, and lack of interest in food.  Patient also had poor appetite.  During this time frame, patient had multiple episodes of chills along with cough and shortness of breath.  He also had nausea and vomiting along with diarrhea 5 days ago.  Patient only lives with his daughter.  Patient was accident for COVID-19 in April 2021.  Over the last 5-6 days, patient has had barely anything to eat and has been very weak.  This morning, he was unable to bear his own weight therefore, his daughter brought him to the emergency department for further evaluation.    Upon arrival to the emergency department, patient was found to have acute hypoxemic respiratory failure.  Chest x-ray was concerning for mild left basilar infiltrate.  He was also noted to have leukocytosis, anemia, hypernatremia, hyperchloremia, uremia, and elevated troponin.  Renal function seems to be at baseline.  Elevated troponin also seems to be lower than baseline.  EKG independently reviewed and negative for any ST elevations or depressions.  No new T-wave inversions noted.  Urinalysis negative.   Patient was discharged approximately 1 month ago after being presented with similar symptoms.  At that time, patient has metabolic encephalopathy was deemed of unclear etiology.  MRI brain was negative for any acute findings.  Carotid ultrasound was also negative.  Hemoglobin A1c was 5.3.  TSH was unremarkable.  Lipid panel was also negative.  Patient was evaluated by Neurology and his mental status changes were deemed most likely secondary to toxic metabolic encephalopathy.  There was no clear source of infection identified.  Chest x-ray and UA were negative.  Also negative for COVID-19.  CT abdomen was also negative.  During the hospitalization, patient did have an episode of aspiration pneumonia and was treated appropriately.  Modified barium swallow was recommended however, daughter refused at that time.