Age: 87.0
Sex: M
Vaccine: COVID19-2
Symptoms: Condition aggravated, Confusional state, Culture urine negative, Cystoscopy, Decreased appetite
Clinical narrative: Patient is a 87 y.o. male patient of, MD with history of HTN, HLD, DMT2, CAD, multiple TIAs on DAT and high-dose statin, presented to Hospital with acute confusion and generalized weakness.   Acute metabolic encephalopathy, improving P/w gen weakness, acute confusion.   At baseline patient has some confusion due to underlying dementia. Etiology unclear-possibilities include dehydration and COVID-19. Patient with history of multiple TIAs on aspirin 81 mg daily, Plavix 75 mg daily and Lipitor 40 mg daily CTA H/N-no acute changes.   MRI brain-severely degraded study.  No acute intracranial abnormality.  Chronic microvascular ischemic changes and multiple chronic lacunar infarction. Numerous foci of susceptibility artifact in the cortical subcortical regions of both cerebral hemispheres and cerebellum.  These are likely represent hemosiderin deposition from prior microhemorrhages with the distribution worrisome for possible cerebral amyloid angiopathy.  Consulted tele-neurologist Dr. Considering the possibility of cerebral amyloid angiopathy, neurologist recommended to discontinue Plavix and continue monotherapy with aspirin. B12 levels normal.  RPR nonreactive Consulted PT/OT.  Recommended SNF. Patient is from transitional living. COVID positive status delayed placement.  DC to SNF for continued Therapy   COVID-19 infection Patient was screened per request of family as his wife tested positive for COVID 3/20/2023. Symptom on admission: Generalized weakness and confusion Patient is vaccinated No O2 requirement.  No treatment indicated. COVID positive status delayed placement.  Patient out of isolation prior to discharge     Gross hematuria, resolved Urinary retention UA with moderate blood.  RBCs> 180.  No WBC, leuk esterase or nitrate on admission. Urine culture and blood culture-no growth Completed 7d empiric IV ceftriaxone Developed acute urinary retention on 3/21/2023 requiring Foley and CBI. Consulted urology.  S/p cystoscopy and TURP by Dr. on 3/22/2023.   Failed voiding trial and reinserted Foley catheter on 3/27/23. Restarted ASA and tolerating without difficulty Flomax increased to 0.8 mg daily with recurrent urinary retention. Patient to follow-up with Dr.'s office for 1 week for voiding trial and postop follow-up Acute blood loss anemia Likely due to gross hematuria Admit Hb 12.6> 12> 9.5> 9.1> 8.5> 7.4>8.8>7.5> 8.3 S/p 1 unit packed RBC transfusion on 3/22/23 No active bleeding   Troponin elevation Serial troponin with a flat trend 34 > 31 > 35 EKG concerning for widened QRS, no prior on file, ER d/w Cardiology and they could compare to old, reported as stable No active CP    HTN BP was running running to the higher side during most of the hospital stay. Home Rx: lisinopril 5 mg daily, Coreg 3.125 mg BID and Norvasc 5 mg daily. As BP was consistently running high, increased Coreg to 6.25 mg BID and Norvasc to 10 mg daily Further titration as outpatient  Diabetes, type II Home Rx metformin 1000 mg BID- continue Accu-Cheks with SSI in the hospital Hemoglobin A1c from 1/18/2023--6.6%   COPD emphysema, previously undiagnosed Long history of pipe smoking Denies history of diagnosed COPD CT showing severe emphysematous changes Chronic cough for many years Started Symbicort and albuterol inhaler-continue Recommend PFTs with PCP once back to baseline   Severe malnutrition; BMI 17 Anorexia Failure to thrive Poor oral intake per nursing staff.  According to daughter, it has been a chronic problem Dietitian on board Consulted speech-recommended puréed diet on 3/30/2023 Discussed with patient's daughter at length about patient's poor oral intake.  According to daughter this has been an ongoing process.  Family will not consider PEG-tube at all   Goals of care After discussing with family CODE STATUS changed to DNR CCA, no intubation. Palliative care followed and signed off. Long-term prognosis poor