Age: 65.0
Sex: M
Vaccine: COVID19
Symptoms: Alanine aminotransferase increased, Anion gap normal, Aspartate aminotransferase increased, Asthenia, Basophil count decreased
Clinical narrative: Hospitalized (12.4.21 - 12.9.2021); COVID-19 positive (12.2.21); Fully vaccinated with moderna x2    BRIEF OVERVIEW:  Admission Date: 12/4/2021 Discharge Date: Dec 9, 2021    Active Hospital Problems   Diagnosis Date Noted POA ? Chronic ulcer of left lower extremity with fat layer exposed (HCC) 12/06/2021 Unknown ? COVID-19 12/04/2021 Unknown   Resolved Hospital Problems No resolved problems to display.    Pre-Existing Active Problems   Diagnosis Date Noted POA ? Pressure injury of sacral region, stage 2 (HCC) 07/03/2021 Unknown ? Skin ulcer of right thigh with fat layer exposed (HCC) 07/03/2021 Unknown ? Skin ulcer of left thigh with fat layer exposed (HCC) 07/03/2021 Unknown ? Incontinence associated dermatitis 07/03/2021 Unknown ? Cellulitis of left lower extremity 07/02/2021 Unknown ? Essential hypertension 07/02/2021 Unknown ? Chronic, continuous use of opioids 07/02/2021 Unknown ? Psoriatic arthritis (HCC)   Unknown ? Infected prosthetic knee joint (HCC) 05/27/2013 Unknown     Discharge Disposition:  inpatient rehab facility    Active Issues Requiring Follow-up:  Patient should be monitored closely for his opioid use.  He has been on high doses of opioids for a long time and has not had his opioid doses decreased and he may require increasing his opioid medications but preferably, he should be helpful opioids as there is no clear indication at this point for chronic opioid use in the setting of his osteoarthritis.  He will need aggressive wound care for his lower extremity wound.    Pending Labs    Order Current Status   Peripheral Blood Culture Preliminary result   Peripheral Blood Culture Preliminary result       DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Encephalopathy due to COVID-19 virus  COVID-19    HOSPITAL COURSE: 65-year-old male with a past medical history significant for chronic opioid use secondary to osteoarthritis who presents due to a fall at home with notable lethargy and altered mental status.   On admission the patient was found to be mildly hypoxic on room air and was found to be quite altered.  CT of the head unenhanced was obtained and this showed no obvious pathology.  Patient had no focal neurological deficit.  His home medications inclusive of his benzodiazepines, opioids, and gabapentin were held due to his altered mental status.  Due to his need for oxygen he was started on dexamethasone 1st COVID-19 infection and thought to warrant admission to the hospital.  With concern for possible left lower extremity cellulitis the patient was also empirically started on vancomycin.   The patient was able to quickly come off of oxygen as his mental status improved and was suspected that his low oxygen level on admission was likely due to a decreased respiratory drive from polypharmacy and a septic encephalopathy.  The patient was able to be discontinued from dexamethasone as he was able to maintain adequate oxygen saturation on room air.   After holding his home centrally acting agents, the patient's mental status greatly improved he was able to return to his baseline mental status but he began to then complain of nausea and vomiting and attributed this to withdrawal from his opioids.  Looking at his home medication list, he was on 3 times a day of morphine extended release at 30 mg.  He was also on alprazolam at 1 mg orally 3 times a day.  He was started back up on opioids but his morphine was changed to 30 mg orally q.12 hours and his alprazolam was changed to 0.25 mg orally 3 times a day p.r.n..  With these medications resumed, patient's withdrawal symptoms improved as well.   Although the patient had initially been started on antibiotics for a presumed cellulitis, patient had no significant leukocytosis, no fever, and his wound overall did not appear grossly infected.  After nasal swab MRSA was found to be negative and blood culture negative, vancomycin was discontinued after greater than 48 hours without antibiotics, patient continued to do well.   As the patient was improving overall, he is evaluated by physical medicine and rehabilitation at thought to be an appropriate candidate for inpatient rehab.   CONSULTS / RECOMMENDATION:    Consult Orders (From admission, onward)                IP CONSULT TO PHYSICAL MEDICINE REHAB              IP CONSULT TO WOUND                INPATIENT PROCEDURES:    Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None     BP 164/64  | Pulse 68  | Temp 36.8 °C (Oral)  | Resp 18  | Wt 99.6 kg  | SpO2 93%  | BMI 33.39 kg/m²    Physical Exam General:  No acute distress  H&P: CHIEF COMPLAINT: COVID-19     Assessment/Plan    ASSESSMENT / PLAN: Acute COVID19 infection Acute hypoxemia  Presenting symptoms: fever, shortness of breath and fatigue   Symptom Onset:  12/1/2021 -Positive COVID-19 PCR on 12/2 -received 2 Moderna vaccinations but booster status unknown -chest x-ray unremarkable -requiring 2 L of oxygen -given Decadron in the emergency department; will continue -not candidate for remdesivir at this time given kidney dysfunction   Acute toxic metabolic encephalopathy -likely multifactorial due to polypharmacy in setting of acute COVID infection -hold sedating medications and continue treatment for acute COVID and acute cellulitis   Acute kidney injury -baseline creatinine is 0.8-1 -likely due to poor oral intake in setting of losartan, hydrochlorothiazide and Lasix use -given 2 L IV fluid in the emergency department; continue gentle IV fluid -trend labs -holding nephrotoxic agents   Acute elevation of liver enzymes -likely due to acute COVID infection -continue trending liver enzymes -is elevating consider imaging   Acute on chronic left lower extremity cellulitis Venous stasis ulcers History prior MRSA infection -will obtain MRSA PCR -continue treatment with vancomycin for now -has wound care  -blood cultures x2 pending -wound consult   Chronic pain with opioid dependence -chronically on morphine ER 30 mg 3 times a day, tramadol 50 mg and Zanaflex -hold meds for now until mentation improves -follows outpatient pain clinic   Essential hypertension -continue metoprolol -hold losartan, hydrochlorothiazide and Lasix due to AKI   Anxiety -hold Xanax given AMS   Full code per discussion with son VTE prophylaxis- sub q heparin           Subjective    HISTORY OF PRESENT ILLNESS: a 65 y.o. male who presents today with altered mental status.  Patient is unable to provide any meaningful history.  Spoke with his son, over the phone who reports that over the past 2-3 days patient has had increased weakness, confusion and fevers.  Patient's wife tested positive for COVID on Monday.  They are both vaccinated for COVID (booster status unknown) but daughter and grandson that lives with them are unvaccinated.  Son reports talking to patient on the phone Wednesday and noted he seemed a little groggy and this has progressively gotten worse.  He was evaluated in the emergency department on Friday but events of this visit are unknown by son and he was discharged home.  COVID test was repeated there and it was positive.  Son was called by his nephew stating his father was not doing well so son went to the house to evaluate.  Found his dad on the floor shaking uncontrollably.  He was confused. Son concerned about polypharmacy. Home pulse ox reading was 80% on room air.  Family had noted  low temperatures and thought thermometer was nonfunctioning. EMS was called for transport to the emergency department for evaluation   On arrival to the emergency department he was noted to be hypoxemic with oxygen saturations 85%.  He improved to mid 90s on 2 L of supplemental oxygen.  Also low-grade temp 100.9°.  Chest x-ray with hypoventilated lungs but no obvious acute process.  Significant laboratory findings included creatinine 2.4, AST 291, ALT 83, lactic acid 1.2, white blood cell count 9.7.  There was a positive COVID 19 PCR on 12/3 noted through community viewer.   He was given 2 liters of IVF, Decadron and IV vancomycin.   Patient Active Problem List Diagnosis ? Infected prosthetic knee joint (HCC) ? Psoriatic arthritis (HCC) ? Cellulitis of left lower extremity ? Essential hypertension ? Chronic, continuous use of opioids ? Pressure injury of sacral region, stage 2 (HCC) ? Skin ulcer of right thigh with fat layer exposed (HCC) ? Skin ulcer of left thigh with fat layer exposed (HCC) ? Incontinence associated dermatitis ? COVID-19