Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Mental status changes, Patient uncooperative, Perfusion brain scan normal, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: Admission diagnoses: Acute onset of word salad and altered mental status concerning for stroke; tongue mass noted concerning for squamous cell carcinoma and heavy alcoholic; alcoholism daily with risk factors for delirium tremens. 62-year-old with history of heavy alcoholism who presented on 1/14/2022 for change of mental status with word finding and inability to speak.  He was seen by emergency room Medicine and Neurology and given tPA for possible left hemisphere stroke. It was difficult for me to get an NIH stroke score scale on him as he would not cooperate with the examination. CT perfusion did not show evidence of large vessel occlusion with no core and no penumbra. The brother stated that he drinks alcohol every day from sun up to sun down and falls frequently at home. There has been some cough. The patient has received a 3 vaccination series with his brother taken him for a booster 5 days ago. His brother is a helper or primary caregiver. The brother noticed acute change in mental status and speech 1/14/2022. The brother also states he has had hip replacement. ICU admission is now undertaken per status post tPA protocol for probable stroke. After receiving tPA patient underwent a repeat head CT on 1/15/2022 which was revealing for hemorrhagic transformation of an acute right occipital infarct with adjacent vasogenic edema with acute blood product measuring 2.9 x 1.9 x 2.4 cm. No mass effect or midline shift was noted. Subsequent head CTs were relatively stable. Neurosurgery evaluated the patient and no neuro surgical intervention was required. Of note, the patient did require Precedex for 3 days due to agitation. This agitation was believed to be secondary to alcohol withdrawal. He was subsequently started on a phenobarbital taper and CIWA protocol. His agitation progressively improved. After coming off of his Precedex drip he was stable for discharge out of the ICU. Of note, tongue lesion was noted on CT. After resolution of patient's agitation, no tongue mass was noted on physical exam performed by Dr. He will be discharged to constant care. He was transferred to the floor 1/19. He improved neurologically though had prolonged encephalopathy due to stroke, alcohol withdrawal, and bacteremia. He had a prolonged stay due to needing to complete isolation for Covid-19 prior to transition to rehab. Once rehab was arranged he was transferred in stable condition. Fever: Covid related, patient tested positive 1/14 and hasn't had any other symptoms. Last fever 2/3. Chest x-ray 2/3 with no infilatrate. Patient did not require oxygen. CVA -MRI BATT-Acute right PCA infarct  -status post tPA with hemorrhagic transformation and vasogenic edema -evaluated by Neurosurgery while in the ICU -repeat CT head-1/17-stable with no mass effect or midline shift mild hydrocephalus -continue aspirin, Lipitor-cleared by Neurosurgery -Repeat CT Head post ASA/LMWH-Unchanged right parieto-occipital intraparenchymal hemorrhage and infarct with no evidence for new or increasing hemorrhage. Near complete resolution of the intraventricular hemorrhage -Echo EF 65 70% negative bubble -continue PT/OT -continue aspirin, statin.