Age: 52.0
Sex: F
Vaccine: FLU4
Symptoms: Metabolic function test normal, Neurological examination normal, Prothrombin time normal, Spinal X-ray, Spinal X-ray normal
Clinical narrative: Got shot and could not remember anything before said date 11/3/16 permanent memory loss. Pt. is a 52y/o female admitted due to AMS. Writer visited pt. at bedside, and attempted to assess and provide her with education, however, pt. would not respond to writer. She remained asleep and did not acknowledge writer's presence. Writer will follow up with pt. once she is alert and oriented. Complete as noted. Discharge Diagnosis: Altered mental status. Patient is a 52 y/o female with PMH of stressor-related disorder, neuropathy, HLD, glaucoma, anxiety, and insomnia presenting, via her son, with AMS. Her son reports that she received her B12 and flu shots here yesterday, came home Thursday afternoon (driving herself), but would not get out of the car and kept asking, "Where am I?". Her son reports this is an acute change and that she was fine previously. He also relays that she has a psychiatric history (bipolar disorder and schizophrenia), but patient is not on medications for said problems (previously seen by Dr.). In the ER patient received 2MG ATIVAN, 5MG of HALDOL for anxiety/agitation getting CT head. CT head was negative for acute abnormalities. Patient had full and broad workup: CT head, CXR, Lspine, and Cspine all showed no acute abnormalities. UA was positive for 2+ blood and troponin, ammonia, PT/INR/PTT, ethanol levels were all WNL. UDS was negative. She was admitted to Medicine for work-up and monitoring of altered mental status. Primary team held all home medications overnight to determine if the AMS was medication overuse/misuse. CBC on admission showed elevated WBC to 12.5, but repeat CBC showed downtrending WBC, likely ruling out infection etiology. Patient had no neck stiffness or viral manifestations. In June of this year, patient had vit D levels in toxic range (117), so BMPs were followed closely, which showed no abnormalities. Repeat vit D levels WNL (43.4), and previous BMPs show no history of hypercalcemia, ruling out hypercalcemia as causation for AMS. Patient had neuro checks Q4hours with no abnormal results. Repeat UDS was still negative. Patient reported feeling in a "fog" and not remembering why she was here yesterday afternoon. The admission events were described to her, and psych was consulted due to previous psych history, possible psych etiology for AMS, and for establishing outpatient f/u as patient is not on any medications for stated psychiatric illness (patient reports a/v hallucinations). Psychiatry recommended continued monitoring for AMS and had no indications of holding patient for further evaluation when primary team deemed patient stable for discharge. Primary team will follow up with psychiatry for establishing outpatient follow up appointment on Monday. All labs today were within normal limits, and patient expressed wishes to go home and that she was feeling better, less "in a fog" than yesterday. On the day of discharge, patient was feeling well without complaints. She was felt to be stable for discharge, and follow up was arranged. Plan-Patient will be discharged home with instructions to monitor closely her medications and how she takes medication, as well as impressing importance of following up with outpatient PCP and psychiatry appt. Patient was instructed to stop taking the following medications: meclizine, zolpidem, loratadine, diphenhydramine, as well ad as son's VYVANSE (was in her medicine bag).