Age: 86.0
Sex: M
Vaccine: COVID19-2
Symptoms: Hyporesponsive to stimuli, Hypoxia, Laboratory test abnormal, Leukocytosis, Malnutrition
Clinical narrative: Per Admit HPI: "Pt is a 86-year-old male with a past medical history of ICH, type 2 diabetes, CKD 3, HFpEF, TAVR, hypertension, hyperlipidemia, gout, malnutrition who presented with hypoglycemia. Patient was noted to be confused, decreased responsiveness,  having poor po intake with blood sugar in the 40s. He was also found to be hypoxic with saturations in the 80s usually not on continuous oxygen. He was given  1 amp of D50 with improvement in his mentation. His blood sugar dropped again in the ED and was found to be in the 40s requiring another D50 bolus.  He tested positive for COVID yesterday at the nursing home and also in the ED today.     In the ED vitals are as follows, temperature none, blood pressure 135/67, heart rate 95, RR 19, and oxygen saturation of 95% on 5 liter nc. Labs results were significant for leukocytosis at baseline, Hgb of 9.2, platelet of 422, Albumin of 1.7. The rest of the CBC and CMP were within normal limits. Troponin pending. Flu swab not checked. Chest x-ray with  atelectasis vs pulmonary edema vs atypical PNA. Patient was given multiple amps of D50, on D5 1/2 NS drip at 75 cc/hr and admitted for further management."   Clinical Summary Toxic metabolic encephalopathy -At baseline patient is A&O x3 -10/24: oriented to self and year; thinks he is at the wildlife office -10/25: oriented to self only -possibly due to recent hospitalization then discharge -patient has been in multiple facilities over the past few weeks??hospital psychosis  -Multifactorial with hypoglycemia, COVID-19, and Hypoxia -continue to reorient as needed -continue to monitor    Hypoglycemia -Recurrent    -Unclear etiology, possibly combination of dehyration, poor po intake, and poor clearance of hypoglycemic agents in s/o of CKD -A1C: 7.3 -On jardiance and glipizide which is held at this time -D5 given as maintenance IV fluids; stopped yesterday once POC was in the 400s -accu checks with SS Humalog coverage and lantus while in hospital  -consulted endocrinology: recommended 10 units lantus while in hospital and continuing home Jardiance and reduced Glipizide at 5 mg every day (hold oral antidiabetics if he is unable to eat)   Acute respiratory failure with hypoxia COVID 19 Suspected Aspiration PNA -Tested positive for COVID 10/23  -Recent COVID test prior to discharge on 10/20 to the facility was negative suggesting he acquired the infection at the nursing home -Sating 100% on 4 liters, was reportedly hypoxic in the mid 80s on EMS arrival -patient tolerating RA -10/24: stopped IV remdesivir -continued Decadron, will not continue at discharge  -Continue augmentin   Type 2 DM -held all hypoglycemic agents  -resumed SSI PRN upon resolution of hypoglycemia -see above Anemia, chronic -Baseline Hgb 10-11 mg/dl -Currently 9.4  -Has had EGD, C-scope in the past -Previsouly received IV Iron most recently July/Aug 2022 -IV Venofer given -Hematology consulted: recommended transfusion if hgb <7   Leukocytosis Thrombocytosis -Off and on chronic issue  -per Dr. with H/O. thought to be reactive -Has had a negative BM biopsy in the past.  -Heme/ONC consulted: patient does not want aggressive work up   Mild AKI on CKD IIIa -likely 2/2 above and meds given -Follows with nephroogy  -Cr: 1.45 -Baseline of 1.3-1.4 -avoid nephrotoxic medications -continue to monitor    HFpEF with History TAVR -Euvolemic  -Continue home metoprolol   History ICH -Recent admission with strokelike symptoms -CT demonstrated hyperdensity of the pons concerning for subacute pontine hemorrhage -Seen by neurosurgery, no intervention recommended -ASA was discontinued -Okay for DVT prophylaxis per neurosurgery   Severe protein calorie malnutrition with cachexia- POA -muscle wasting -Dietician consulted: recommended PEG ---long discussion with patient and his wife (via phone), patient is still confused at this time but does not want the PEG, patient's wife also does not want the patient to have PEG placed   Dysphagia -seen by speech -NDD diet