Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: Rales, Restlessness, Rhonchi, SARS-CoV-2 test negative, Sinus tachycardia
Clinical narrative: Patient brought in by rescue squad with severe stroke-like symptoms.  Chief complaint of extreme confusion.  Temperature 37.8 degrees centigrade. Pleasant 83-year-old male brought to emergency department via ambulance for evaluation of confusion.  The patient's wife states that the patient has had intermittent confusion for the past 2 days but it became acutely worse this morning.  Patient's wife also states that the patient has had a cough for the past 2 days.  The patient does complain of shortness of breath.  Patient has known history of COPD.  The patient and his wife denies any reports of fevers.  The patient denies any chest pain.  He denies abdominal pain, nausea or vomiting.  Patient's wife states that the patient has had some loose stools.  His wife reports that he was using the bathroom frequently last night but does not know if he was having loose stools or if it was due to urinary frequency.  The patient does complain of having occasional dysuria as well as urinary frequency.  He states that he is in the hospital but cannot tell me the month, the year or why he is in the hospital.  Altered mental status, unspecified R41.82   Low-grade temp, 37.8 °C, nontoxic-appearing.  Presented to emergency department with altered mental status, patient was alert to person, stated that he was in the hospital.  Patient did have difficulty remembering his wife's name and remembering his caregiver as well as the names of his children.  Patient restless at times.  Patient globally weak.  No arm drift or leg drift.  A stroke work-up was initiated.  Patient had a CT head without contrast which was negative for acute fracture or hemorrhage.  Showed vasculopathic changes.  Patient did have some periods where his mentation seemed to improve but then would become confused again.  Covid swab obtained, negative for COVID-19, influenza a and B not detected.  Pupils equal round and reactive to light.  Patient is normally alert and oriented x4.  UA unremarkable.  Chest x-ray obtained, do not appreciate any focal infiltrate.  CMP shows normal electrolytes.  Patient has a mildly bumped CO2 level of 31, upper limit of CO2 is 30.  It is possible the patient's confusion may be related to hypercapnia however it is very minimally bumped up.  The patient will need to have further work-up due to his altered mental status as it does not seem to be a clear-cut answer to the cause of it.  The patient has been confused for several days according to his wife with worsening today.  Patient did request transfer to Facility, his wife was in agreements with transfer to Facility.  Spoke with hospital, spoke with Dr.  who did accept the patient for transfer.  The patient will be transferred by ambulance to the Facility, the Hospital did state that the patient was travel eligible and they would arrange for transport of the patient to their facility.   2. COPD with exacerbation J44.1   Presented to emergency department with altered mental status.  Patient was found to be dyspneic with expiratory wheezing bilateral upper lobes, coarse rhonchi and crackles in his bilateral bases.  No JVD appreciated.  ECG showed sinus tachycardia, no ST segment elevation or acute ischemic changes.  proBNP was 1114.  Patient does not have any documented history of heart failure.  Patient was given a DuoNeb and had improvement with his shortness of breath.  Had a loose cough.  Patient had recurrence of wheezing and was given an additional albuterol nebulizer treatment in the emergency department.  Patient given dexamethasone 6 mg IV.  Covid swab negative.  Patient has known COPD.  1 view chest x-ray obtained, do not appreciate any focal infiltrate.  Suspect the patient may have COPD exacerbation causing his shortness of breath.   3. Elevated brain natriuretic peptide (BNP) level R79.89     Orders:   albuterol, 2.5 mg = 3 mL, Soln, NEB, q4hr (interval), PRN shortness of breath or wheezing, Routine, Start date 12/30/21 12:06:00 CST, 12/30/21 12:06:00 CST  dexamethasone 10 mg/mL injectable solution, 6 mg = 0.6 mL, Soln, IV Push, Once, NOW, Start date 12/30/21 14:18:00 CST, Physician Stop, Stop date 12/30/21 14:18:00 CST, 12/30/21 14:18:00 CST  Ativan, 0.5 mg = 1 tab(s), Tab, Oral, TID, PRN anxiety, Routine, Start date 12/30/21 13:30:00 CST, 12/30/21 13:30:00 CST  EKG, 12/30/21 9:27:00 CST, Stop Date 12/30/21 9:27:00 CST, Walk, No, No, Standard Precautions, stroke alert  Insert Straight Catheter, 12/30/21 9:30:00 CST  Patient Transfer Order, 12/30/21 12:06:00 CST, transfer   XR Chest 1 View Portable, 12/30/21 9:29:00 CST, Routine, 12/30/21 9:29:00 CST, cough, SOB, No, Transport Mode: Walk, , No, , No, Rad Type  ER Level 4  Informed Dr. with plan of care and agrees with plan of care.  Patient Discharge Condition  Stable  Discharge Disposition  Transfer to Facility at 1422