Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Constipation, Decubitus ulcer, Dementia, Electrocardiogram normal, Encephalopathy
Clinical narrative: Patient is a 77 y.o. female patient of MD with history of HTN, DM2, anxiety presented with altered mental status secondary to sepsis and AKI on CKD.  Hospital course complicated by worsening encephalopathy, anemia, COVID-19 and Klebsiella bacteremia.    Goals of care discussion Pt DNRCCA, DNI Palliative following Given condition during stay plan to transition to hospice at SNF, pending arrangements  Patient transferred to for hospice    Acute metabolic encephalopathy Dementia  Secondary to Sepsis, COVID CT Head (10/1) with no acute abnormality, worsening severe chronic microvascular disease MRI brain (10/10) with Cerebral atrophy.  Severe chronic small vessel ischemic disease.  No acute infarct. Pt talkative and follows commands at baseline, but not oriented to place/time Remains minimally verbal (11/2), not following commands since admission Neurology evaluated, no additional testing recommended, signed off  Lacks capacity, daughter is guardian   Uncontrolled HTN  Stopped clonidine, hydralazine and amlodipine Continue coreg, amlodipine added 10/30 Coreg increased to 6.25mg BID (10/31), hydralazine added 11/1 BP approximately 180/90  Prn labetolol and hydralazine in place Monitor BP   CKD Stage 4  AKI - resolved Baseline Cr ~ 2-2.5, Cr 2.67 on admission, worsened to 4.2 (10/23) Bladder scans, no retention thus far  Nephrology following Has been on and off bicarb gtt, resumed (10/20), changed to D5LR (10/21) as bicarb normalized and pt not eating Fluids stopped 10/29  Cr now 2.37 (11/2) Nephrology following; continue to hold IVF    Acute on chronic Anemia  Hgb baseline ~ 8-9 No s/sx of bleeding Iron studies (10/18) show decreased iron saturation suggestive of mild deficiency S/P IV venofer S/p 1U PRBC (10/14) GI consulted, family declining endoscopy Hgb remains around 6.8 (10/28), will stop checking  If rechecked would transfuse for Hgb < 6.5 or clinical instability    DM2, not on any home meds A1c 6.9 (10/1) SSI Monitor blood glucose    HLD Continue home Atorvastatin DM2, not on any home meds A1c 6.9 (10/1) SSI Monitor blood glucose    HLD Continue home Atorvastatin   GERD Continue Pantoprazole   Depression Continue home Zoloft   Left heel deep tissue pressure injury, not POA  Stage 3 left ischium pressure injury, not POA Wound care following   Sepsis, POA, and recurrent sepsis developed after admission Klebsiella Bacteremia Sepsis on admission, thought to be due to UTI vs Colitis, completed abx course of Vanc/Zosyn (10/8) Febrile to 102.9 (10/19), Leukocytosis max 26.88k (10/22); now fever-free and WBC improving COVID-19 positive (10/20) CXR (10/20) with bilateral infiltrates Blood cx 2/2 (10/20) with Klebsiella Pneumoniae, unclear if due to PNA vs UTI S/P IVF bolus 500mL x 1, then continuous IVF with D5LR  On Ceftriaxone, completed  10/28    Covid-19 Virus Infection - out of isolation Date of onset of symptoms: 10/19 Symptoms present on admission: None, developed fever 10/19 Date of covid positive test: 10/20 Vaccination status: vaccinated Imaging: CXR (10/20) with new patchy bibasilar opacities with small L pleural effusion Current oxygen requirements: None Medical therapy: not indicated Consultants following: ID, not a candidate for paxlovid due to renal function Isolation end date: 10/30 Patient meets the following criteria for symptom based strategy for discontinuing transmission-based isolation precautions: Mild to moderate illness and are not severely immunocompromised: at least 10 days have passed since symptoms first appeared, AND at least 24 hours have passed since last fever without the use of fever-reducing medications, AND symptoms (e.g., cough, shortness of breath) have improved.    Elevated troponin Trop 94 -- > 97 -- > 86, flat EKG nonischemic Likely in the setting of CKD No further work up at this time   Constipation, resolved Severe stool burden on CT w stool impaction Resolved with bowel regimen Cont chronic bowel regimen