Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Increased bronchial secretion, Intentional medical device removal by patient, Magnetic resonance imaging head, Medical diet, Mental status changes
Clinical narrative: Patient is a 78 y.o. female who presented from facility on 11/29/2022 with confusion and hypoxia. Found to have COVID-19 with acute hypoxic respiratory failure, complicating plans to return to memory care unit (isolation through 12/18).  Clinical course further complicated by worsening mental status and intolerance of p.o.  Neuro oncology team involved with care.  She was able to eventually recover ability to tolerate p.o. intake and was discharged to rehab facility   Discharge Diagnosis and Associated Hospital Course   COVID-19 Infection without sepsis or systemic illness  Acute hypoxic resp failure, resolving Initially presented with dyspnea, cough, metabolic encephalopathy, hypoxia.  Tested positive at facility 11/29. Previously vaccinated and boosted with last booster 5/10/2022 -Was hypoxic, but this eventually resolved -She is status post Decadron and remdesivir. -Patient immunosuppressed at baseline and was on steroids due to GBM, and was also significantly hypoxic qualifying for severe category of COVID illness.  Plan for 20-day total period of isolation (through 12/18)   Dysphagia Likely worsened by acute infection in the setting of her GBM with airway secretions - SLP following, s/p MBS 12/2 with advancement in diet to ground, nectar thickened liquids; meds resumed, initially seem to be tolerating -Had a prolonged n.p.o. recommended by SLP. -NG placed 12/9, however patient removed it -Patient's PO intake continues to be better, on puree and thin liquids -Continue to work SLP in the outpatient setting and at skilled nursing.   Acute Metabolic Encephalopathy Presented with worsening confusion over days; suspect multifactorial from COVID-19, hypoxic respiratory failure, GBM, and sedating medications.  Appears to wax and wane. -CTH: known R frontal GBM with improved vasogenic edema of the right cerebrum and new right internal capsule lentiform nucleus involvement.  Urinalysis was unrevealing for infection, blood and urine cultures were negative. -Repeat head CT obtained 12/6 unchanged -Neuro-oncology signing off Candida Intertriginous Rash -Noted on the patient's chest in the breast region -Patient's left arm is flaccid and in between this, and mobility and warmth of the room did develop significant humidity leading to this rash. -- Recommend nystatin powder twice daily to 3 times daily administration to rash.   GBM Cerebral vasogenic edema Status post craniotomy and resection 10/19/2021 by Dr.  Had XRT and was on chemotherapy with Dr.  -CT Head 11/29 reconfirmed GBM, improved vasogenic edema; arrived on Decadron per OP specialists  -Was previously reviewed with neuro/oncology. They feel CTH is improved compared to prior -Neuro oncology consulted, holding off on further neuroimaging at this time. - They will hold bevacizumab until full recovery from COVID -Neuro-oncology signing off, recommending continuation of dexamethasone 6 mg daily and continuation of Keppra 1000 twice daily and Trileptal 600 twice daily.  Brain MRI on 1/5/2023. - Palliative met with family, they would like to continue current medical measures.   Acute left thigh pain -Etiology unclear, initial thoughts for muscular etiology versus hip pathology versus proximal DVT versus medication side effect. -No physical changes on exam, rash, spasm noted.  Patient with more significant pain on the anterior aspect of the left thigh but also wrapping around to the lateral aspect of the thigh.  He is neurovascularly intact. -CPK was negative.  X-ray of the left hip 12/15 with no definitive fractures -Daughter states that the patient does not have recurrent episodes of significant left-sided pain and this appears to be consistent with those.   Seizure disorder - on Keppra and Trileptal at home -spot EEG 11/8 without evidence of epileptiform discharges or seizure activity -Continue home AEDs -Neuro oncology involved with care, seizure activity is not suspected.  They have signed off.   History of hyponatremia -Suspect multifactorial due to poor p.o. intake and SIADH in context of GBM and cerebral edema; arrived on salt tablets -Sodium 130->140 (12/4)  -Salt tablets held on admission, had been on Lasix for dry lung strategy with COVID, now off  -Sodium tablets continued on discharge.   History of PE/DVT -Per history, diagnosed in December 2021.  On Eliquis at home -Continue anticoagulation   Restless leg syndrome -Continue Mirapex   Anxiety -Continue home Lexapro, Klonopin, Remeron.     Obstructive sleep apnea -With hypoglossal nerve stimulator   Chronic normocytic anemia -Likely chronic inflammation from glioblastoma multiforme. -Currently at baseline   GERD -Continue home PPI   Severe Malnutrition -Per ASPEN