Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Abnormal behaviour, Anticoagulant therapy, Asthenia, Blood creatinine normal, Blood folate normal
Clinical narrative: brought into the emergency department by his daughter for evaluation of shortness of breath and confusion in the setting of recent Covid diagnosis.  Apparently the patient had begun to feel ill around 12/23.  He tested positive for Covid yesterday, 12/28.  When the patient's daughter went to check on him this morning, he seems somewhat confused and did not appropriately come to the door to let her in.  He also seems somewhat weak and had some modest shortness of breath.  She had a pulse oximeter which with activity demonstrated that the patient consistently dropped into the mid to low 80% range.  He has not been eating or drinking well.  He has occasional dry cough but no significant sputum production.  The patient apparently has been having drenching sweats and fevers.  Denies chest pain.  Denies new or worsening lower extremity edema.  No significant diarrhea.  He has no other concerns at this time. Patient is an 80-year-old gentleman with history of T2DM, HTN, HLD, RA, hypothyroidism and numerous other medical conditions.  He is fully vaccinated against COVID-19.  He started to feel unwell on 12/23/2021, tested positive for COVID-19 on 12/28/2021.  He presented to ED on 12/29/21 with complaints of SOB, nonproductive cough, confusion, chills, subjective fever, diaphoresis and hypoxia with O2 sat in the mid to low 80s.  His initial vital signs were temp 99.3 °F, BP 150/77, HR 102, RR 16 and 92% sat on RA.  Chest x-ray with bilateral lower lobe infiltrates, left greater than right.  COVID-19 nasopharynx swab by PCR positive in the ED.  Admitted with diagnosis of COVID-19 pneumonia   COVID-19 pneumonia: ---   Fully vaccinated against COVID-19 ---   Onset of symptoms 12/23/2021 ---   Tested positive on 12/28/2021 ---   Confirmed COVID-19 positive at MGH ED on 12/29/21 ---   Patient not hypoxic, on room air since admit ---   Procalcitonin level 0.09, thus superimposed bacterial infection unlikely ---   He does not qualify for Decadron or other Covid therapy ---   No longer on isolation ---   Enoxaparin 105 mg sq bid since D-dimer is > 1.0 on admit.  Stop trending D-dimer. This will be discontinued at discharge   Acute metabolic encephalopathy: ---   Due to COVID-19 pneumonia. ---   Admit UA negative for UTI ---   Procalcitonin level was 0.09, thus systemic bacterial infection unlikely ---   CT head w/o contrast on 1/5/21 was negative for acute intracranial pathology but revealed subdural hygroma ---   MRI brain w/ & w/o contrast 1/6/22 negative for acute intracranial pathology ---   Phone consult with neurology service and prelim assessment is acute metabolic encephalopathy due to COVID-19 infection but differential diagnosis includes early dementia.  Outpatient referral to neurology clinic recommended.   ---   If change in mental status due to COVID-19 infection, then expect it may last 3 to 4 weeks.   ---   UA negative for the 3rd time since admit. ---   TSH wnl ---   Vitamin B12, folate normal and RPR is negative ---   Patient may need further work-up for dementia with neuropsych testing as an outpatient if his cognition remains altered ---   Outpatient EEG to rule out seizure disorder also entertained ---   Mental status remains altered at this time ---   PT/OT recommending 24/7 supervision.  Most likely discharge  on 1/14/2022.  Patient will require outpatient follow-up with neurology.   RA: ---   On PTA prednisone and Arava ---   Patient also gets Rituxan infusions every 7 months.  He just had this in December.   T2DM: ---   Continue NovoLog SSI ---   Continue PTA baby aspirin ---   PTA Januvia on hold   HFpEF: ---   Compensated ---   Lasix resumed at 20 mg twice a day given trace bilateral lower extremity edema ---   Follow BUN and creatinine   HTN:   ---   BP under good control ---   Hold PTA ramipril and blood pressure remained stable ---   Has as needed hydralazine   HLD: ---   PTA atorvastatin.   AKI ---   Likely prerenal and PTA Lasix and PTA ramipril were on hold ---   Admit creatinine was 1.18 ---   Avoid nephrotoxins ---   Lasix resumed on 1/9/2022.  Creatinine has remained stable.   Hypothyroidism: ---   TSH on 1/6/2022 is 3.4 ---   Resume PTA levothyroxine   Anemia ---   Hgb was 13 g and is now at ~ 10 and stable ---   Patient is on enoxaparin 1 mg/kg subcu every 12 hours and there is no evidence of bleeding for D-dimer more than 1 ---   Monitor   BPH ---   Continue PTA Proscar and Flomax   Hypomagnesemia: ---   Replaced per protocol   Diet:   Heart healthy, carbohydrate consistent diet CODE STATUS:   Full Disposition: Discharge to (facility) when bed available.