Age: 81.0
Sex: F
Vaccine: COVID19
Symptoms: Staphylococcus test negative, Stress, Toxic encephalopathy
Clinical narrative: PROGRESS NOTE 2/6/2022 ASSESSMENT/PLAN Patient is an 81 yo female w/ h/o chronic pain secondary to rheumatoid arthritis (on suboxone, prednisone, gabapentin), depression/anxiety, paroxysmal atrial fibrillation (in the setting of serotonin syndrome) previously on apixaban (discontinued due to several hospitalizations for severe GI bleeding), diagnosed with COVID-19 1/17/2022, chronic pain due to myofascial pain syndrome, and just seen in emergency department 1/26/2022 with dehydration who was admitted to hospitalist medicine service from local ED on 1/27/2022 with acute toxic vs metabolic encephalopathy, colonic inflammation due to obstipation and COVID-19 pneumonia.    Acute metabolic encephalopathy Suspect undiagnosed dementia with behavioral disturbances:  ---   Initial confusion and lethargy were attributed to acute processes such as dehydration, sepsis, Covid, etc.)  ---   MRI limited w/o contrast per stroke protocol on 1/26/22 revealed chronic microvascular infarcts o/w no acute intracranial pathology ---   CT head w/o contrast on 1/30/22 was negative for acute pathology ---   Neuro exam non-focal.   ---   She has excessively somnolent from day of admit until 2/5/22.   ---   Pt's meds were adjusted on by Dr. ---   Palliative, comfort and hospice care discuused. ---   She is currently on! ---   Scheduled seroquel 25 mg po qam and 100 mg po qhs ---   PRN seroquel 25 mg every 6 hours ---   PRN IV haldol  ---   12 lead EKG QTc ~370, performed 2/4/2022  ---   Discontinue dexamethasone 2/4/2022 ---   Discontinued Cymbalta 2/1/2022 (hx of serotonin syndrome)  ---   Discontinued as needed Ativan 2/4/2022 ---   Trying to avoid narcotic analgesia ---   Holding PTA gabapentin and Robaxin (can both cause CNS depression) ---   She has been awake, alert and follows simple command past 2 days. ---   She still yells for help but not too often ---   She will need eval by psychiatry for antipsychotic meds adjustment ---   She will need neuropsych testing and neurology eval for official diagnosis of dementia ---   Continue above medications and consider transferring to HCF     Acute hyypoxic resp failure due to COVID pneumonia and probable bacterial pneumonia ---   Fully vaccinated but not bloosted ---   Covid symptoms began on 1/13/2022 ---   She tested positive on 1/17/2022 ---   Admit chest x-ray without infiltrate but follow-up chest x-ray revealed patchy bilateral infiltrate ---   She was not hypoxic on arrival, O2 sat was 91% in the ED. ---   She has required O2 supplement since admit ---   Peak O2 supplement was 2 L NC ---   She was able to wean off O2 supplement ---   Discontinued dexamethasone 2/4/2022 to further mitigate the patient's agitation and behavioral disturbances ---   She has been on enoxaparin 40 mg sq daily since her d-dimer was < 1 ---   Full barrier isolation discontinued on 2/1/22 ---   She is considered Covid recovered ---   See below for tyreatment of bacterial pneumonia     Suspect ischemic colitis Obstipation Uncontrolled abdominal pain:  ---   He did not have hematochezia or diarrhea ---   Resolved with more aggressive bowel regimen as recommended by GI.  ---   Admit CT AP w/ IV contrast on 1/27/22 revealed findings consistent with a nonspecific infectious or inflammatory colitis extending from the proximal ascending colon through the sigmoid colon. ---   Repeat abdominal CT 1/30/2022 demonstrated interval decrease in colon wall thickening with no adjacent fluid or fat stranding.   ---   She was seen by GI and colonoscopy not necessary.  Acute abdominal pain was due to ischemic colitis related to colonic obstipation, since resolved with more aggressive bowel regimen/enema.  Acute mesenteric ischemia due to arterial/venous occlusion ruled out.  Bowel obstruction/ileus also ruled out. Looking through patient's chart, the pt has history of developing ischemic colitis in the past and likely related to small vessel atherosclerosis to watershed area feeding descending colon, exacerbated by stress (dehydration, infection, etc).  ---   GI  signed off 1/31/2022 ---   Enteric precautions discontinued  ---   BID miralax -> lactulose 20 g daily starting 2/3/2022  ---   PRN Toradol for analgesia, holding off narcotic analgesia due to confusion      Right lower lung bacterial pneumonia (in relatively immunocompromised host)  Severe sepsis   Toxic encephalopathy: ---   While the patient was never exhibiting fever, tachycardia, leukocytosis, and pronounced tachypnea, the patient was more somnolent and less responsive starting 1/30/2022.   ---   1/31/2022 chest CTA demonstrated groundglass opacities to right lower and midlung which were pathognomonic findings for Covid pneumonia; however, chest CTA also demonstrated more dense, patchy opacities that appeared more consistent with bacterial pneumonia.  ---   Serum procalcitonin 0.04 --- > 0.15 --- > 0.13 ---   Patient's increased somnolence c/w severe sepsis due to right lower lung bacterial pneumonia, which formed as a complication for the patient's COVID-19 pneumonia.  ---   Aspiration ruled out - patient seen by speech pathology.   ---   Head CT without acute intracranial process. ---   Completed IV cefepime and doxycycline initiated 1/30 - 2/5/2022  ---   MRSA nares negative, discontinue vancomycin ---   CRP has been < 1.0  ---   NGTD from blood cx collected on 1/27 and 1/30/22     Chronic pain Myofascial pain syndrome  Rheumatoid arthritis: ---   Continuing PTA prednisone 2.5 mg p.o. twice daily.   ---   Holding PTA gabapentin and Robaxin for chronic pain given the patient's confusion/CNS depression.  ---   PTA cymbalta discontinued indefinitely.     Essential HTN:  ---   Patient having more severe inpatient HTN as of late (SBP 180s) perhaps related to agitation.  ---   PTA lisinopril and metoprolol ---   PRN IV hydralazine for severe HTN    Paroxysmal atrial fibrillation:  ---   Pt's atrial fibrillation was thought to be in context of serotonin syndrome which has since resolved.  ---   Pt longer takes apixaban due to severe GI bleeding requiring hospitalization.     Deconditioning: ---   PT/OT following ---   Probable transfer to HCF in 1-2 days.       GERD:  ---   PTA pantoprazole 40 mg po bid