Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Magnetic resonance imaging head abnormal, Mental status changes, Metabolic encephalopathy, Metastases to central nervous system, Proteus test positive
Clinical narrative: 78-year-old female with past medical history of metastatic melanoma with hemorrhagic brain lesions admitted for altered mental status and fever.  Found to have COVID-19 infection.  Started on Decadron due to mild hypoxia.  Also found to have UTI with 50-100 K. Proteus species.  Initiated on cefdinir for UTI treatment.  Also on oral vancomycin for C. difficile prophylaxis.  MRI brain showing worsening and new metastatic brain lesions.  Evaluated by radiation oncology with plans for further brain radiation treatment.  Radiation oncologist wanted patient to stay on steroids and they will taper her steroids as an outpatient.  Also noted to be hyponatremic during hospitalization likely secondary to SIADH in setting of me Radiation oncologist wanted patient to stay on steroids and they will taper her steroids as an outpatient.  Also noted to be hyponatremic during hospitalization likely secondary to SIADH in setting of metastatic brain disease.  Improved with fluid restriction.   Sepsis Lactic acidosis COVID-19 infection -Presented with fever, tachycardia, tachypnea, mildly hypoxic.  Likely secondary to COVID-19 infection. -Noted to have elevated lactic acid 4.4 which improved to 1.9 with hydration. -Blood cultures NGTD.  UA without signs of infection.  Urine culture less than 100 K. Proteus species.  Defer antibiotics at this time as patient is not having urinary symptoms. -Required 2 L nasal cannula on admission.  Chest x-ray negative for acute process and improving right lung infiltrate.  Initiated on Decadron 6 mg daily x10 days.  Remdesivir deferred due to clinical improvement after steroid initiation. -Will need home O2 at discharge Acute metabolic encephalopathy -Family reports worsening confusion over the past couple weeks.  Suspect due to recent brain radiation treatments in setting of brain lesions as well as COVID-19 infection -Mental status appears to wax and wane according to family.  Currently at mental baseline.   Metastatic melanoma with multiple hemorrhagic brain metastases -Known history of stage III right arm melanoma s/p wide local excision and receiving adjuvant nivolumab.  Also with known multiple intracranial lesions concerning for hemorrhagic metastases.  Completed brain radiation treatment on 6/15/2023. -CT brain on admission shows stable lesions. -Evaluated by radiation oncology, okay to keep on steroids for now -MRI pituitary protocol without pituitary abnormalities but does show worsening and new metastatic brain lesions.  Discussed findings with family, further management per radiation oncology.   Hyponatremia -Likely secondary to SIADH in setting of metastatic brain disease -Urine sodium 75 and urine osm 446 -A.m. cortisol 18 -Sodium 126 on admission.  Baseline sodium around 133-137.  -Received NS bolus and D5 bolus on admission.  Sodium stable at 128.  Hold on further fluids.  Fluid restriction added.  Continue to monitor.   COPD -No wheezing on exam.  Does not appear to be on inhalers at home.   Hypertension -Blood pressures improved.  Restart patient's home Aldactone.   Type 2 diabetes, non-insulin-dependent -Home regimen includes metformin and glipizide.  Also on Lantus 14 units nightly but only when on high-dose steroids. -Holding home oral diabetic medications during hospitalization -Blood sugar trend <200.  Continue corrective sliding scale.  A1c 9.3.  Restart home Lantus.  Continue metformin and glipizide at discharge.   Hypertension -Home regimen includes amlodipine, Coreg, lisinopril, Aldactone, and Imdur.  Also on Lasix as needed. -Antihypertensives held on admission due to soft pressures.  Blood pressure is now elevated so we will begin to restart home blood pressure meds with parameters.  Continue to hold amlodipine for now.  Also holding Lasix due to hyponatremia.