Age: 41.0
Sex: M
Vaccine: COVID19
Symptoms: Ammonia increased, Anion gap, Anticoagulant therapy, Antinuclear antibody negative, Arterial catheterisation
Clinical narrative: Hospitalized (3.19.22 - 3.26.22); COVID-19 positive (3.19.22);  fully vaccinated PLUS Booster J&J x1 + moderna x1 D/c Summary:  Discharge Summary  DO (Physician) ? ? General Medicine BRIEF OVERVIEW: Discharge Provider:, DO Primary Care Provider at Discharge:, PA-C  Admission Date: 3/19/2022 Discharge Date: 03/26/2022  Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 03/20/2022 Unknown ? Alcoholic hepatitis with ascites 03/20/2022 Unknown ? Full code status 03/20/2022 Unknown ? Thrombocytopenia (HCC) 03/20/2022 Unknown Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Acute respiratory failure with hypoxia and hypercapnia (HCC) 03/20/2022 03/26/2022 Unknown ? Encephalopathy 03/20/2022 03/26/2022 Unknown ? Pneumonia 03/20/2022 03/26/2022 Unknown ? Metabolic acidosis 03/20/2022 03/26/2022 Unknown Discharge Disposition: Home without services   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hepatic encephalopathy (HCC) Severe sepsis (HCC) Pneumonia due to infectious organism, unspecified laterality, unspecified part of lung Respiratory failure with hypoxia (HCC) Acute respiratory failure (HCC)   HOSPITAL COURSE: Patient is a 41 yo man with history of EtOH abuse and elevated LFTs, brought in to the ER by his neighbor who found him confused, tremulous and diaphoretic. In ER  patient was found to be febrile. COVID-19 positive with metabolic and respiratory acidosis, ammonia 343, AST 312, ALT 37, T bili 2.6. He was minimally oriented, agitated and unable to provide history.  He became hypoxemic and was urgently intubated.  Chest CT notable for extensive airspace disease. Abdominal CT with hepatic steatosis and ascites. Paracentesis completed w/2500 ml removed. RUQ US noted gallbladder sludge and mild gallbladder wall thickening and intramural edema which is likely reactive in the setting of liver disease and ascites; findings suggestive of portal HTN. Patient w/encephalopathy - tox screen positive for ethanol (lvl <10) and no illicit drugs were detected. HCT unremarkable and cEEG negative for seizure. Ultimately encephalopathy resolved and patient was able to be extubated. He was transferred to the internal medicine service. He completed a course of IV abx for possible bacterial pneumonia. He completed a steroid course for COVID pneumonia. Patient had an unwitnessed fall and was found down. He was confused. CT head with soft tissue contusion without underlying fracture or acute intracranial abnormality. CT cervical spine with no acute fracture or malalignment. Trauma was consulted and evaluated the patient. Shortly after patient was found down he had a witnessed seizure. Neurology was consulted. He became increasingly agitated and did require restraints. Psychiatry was consulted as patient was thought to be in DTs. Patient was treated with ativan and haldol. He did improved and was able to be removed from restraints. MRI brain was obtained and unremarkable. Patient was informed of state law of no driving until 6 months seizure free. Patient was evaluated by PT/OT who recommended HHC and 24/7 assist. Family felt they could provide this. He was recommended to follow up with his PCP and GI. He was given substance abuse resources for alcohol abuse. He was discharged home in stable condition.   CONSULTS / RECOMMENDATION: ICU GI   INPATIENT PROCEDURES: Surgery and Procedures     None Non-surgical Procedures (From admission, onward)   Start        03/20/22 1339    PARACENTESIS  R       03/20/22 0857    INTUBATION  R       03/20/22 0617    BRONCHOSCOPY  R       03/20/22 0207    INSERT ARTERIAL LINE  R      BP 97/68  | Pulse 97  | Temp 36.8 °C (Oral)  | Resp 16  | Ht 1.79 m  | Wt 91.5 kg  | SpO2 98%  | BMI 28.56 kg/m²  FIO2 (%): 30 % Physical Exam Constitutional:   General: He is not in acute distress. Looks improved today HENT:     Head:    Comments: Scalp hematoma present    Nose: Nose normal.  Eyes:    Extraocular Movements: Extraocular movements intact.  Cardiovascular:   Rate and Rhythm: Tachycardia present.  Pulmonary:    Effort: No respiratory distress.     Comments: Diminished breath sounds Abdominal:    Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:     General: Skin is warm and dry.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.    3/20/22 H&P:  CHIEF COMPLAINT: Acute respiratory failure with hypoxia and hypercapnia (HCC ASSESSMENT / PLAN: Patient is a 41 yo man with history of EtOH abuse and elevated LFTs, admitted 3/19/22 with fever, encephalopathy and respiratory failure.     He had called his neighbor to report he had not been feeling well for a few days.  The neighbor found him confused, tremulous and diaphoretic and brought him to the ED.  Tmax 39.0.  Tachycardic to 160, BP stable.  COVID-19 positive.  Metabolic and respiratory acidosis present, with normal lactate.  Ammonia 343, AST 312, ALT 37, T bili 2.6.  He was minimally oriented, agitated and unable to provide history.  He developed progressive hypoxemia requiring fairly urgent intubation.  Chest CT notable for extensive airspace disease in RML, RLL, LLL.  Abdominal CT with hepatic steatosis and ascites. ASSESSMENT / PLAN * Acute respiratory failure with hypoxia and hypercapnia (HCC) Assessment & Plan Due to pneumonia and encephalopathy, COVID-19 positive   Intubated 3/19/22 in ED Current respiratory support:  Vent Settings: FIO2 (%): 50 % Type of Mechanical Vent: Hamilton Mechanical Rate: 16 breaths/min Set/Target Tidal Volume: 450 PEEP (cm H2O): 12 cm H2O Inspiratory Time Set: 0.8 second(s) Lung mechanics: Plateau Pressure: 25 cmH2O Peak Pressure: 26 cmH2O Patient-ventilator interaction: o synchrony ? Neuromuscular blockade: No  ? Proning:No  ? Body Position: per Continuous Lateral Rotation Therapy Sedation: o RASS goal: -4 o propofol o fentanyl VAP prophylaxis: Chlorhexidine  GI prophylaxis: PPI DVT prophylaxis: subcutaneous heparin Plan:  Goal TV 4-6 ml/kg with pPlat <30, ph 7.24 - 7.4 Goal SpO2 88-92%, PaO2 55-65    Bronch with BAL completed, await culture results Empiric coverage with vancomycin, Zosyn Dexamethasone for COVID, as below -Encephalopathy Assessment & Plan Likely multifactorial - respiratory failure, pneumonia, EtOH abuse / withdrawal (?), elevated ammonia /  alcoholic hepatitis, seizure (?) 3/20 head CT without acute pathology Drug screen positive for ethanol, though level < 10 Comprehensive drug screen pending EEG requested Trending ammonia level - lactulose started Daily thiamine, folic acid -Pneumonia Assessment & Plan Chest CT 3/20 with extensive airspace disease in RML, RLL, LLL  - radiographic appearance more consistent with bacterial process - CAP or  aspiration COVID-19 positive, unclear clinical significance currently   Bronch with BAL 3/20 - minimal clear secretions, BAL in RML with blood tinged fluid, cultures pending Strep, Legionella Ag pending Vancomycin 3/20 -  Zosyn 3/20 -  -COVID-19 Assessment & Plan Test positive 3/19/22 Vaccinated:  J&J 4/6/2021, Moderna 11/17/2021 Reportedly had COVID infection in summer 2021? (Reported in outpatient note, no testing in chart) -Current imaging more consistent with bacterial pneumonia ABX as above Dexamethasone 6 mg daily 3/20 -  -Alcoholic hepatitis with ascites Assessment & Plan Presenting with fever, encephalopathy, AST 312, ALT 37, T Bili 2.6, INR 1.3 3/20/22 Abdominal CT with contrast:  hepatic steatosis, patent portal veins, no biliary dilatation, normal size spleen, large ascites -Evaluated by GI at HCF 2/7/2022, outpatient EGD planned (not yet done) LFTs in similar range in Jan 2022, also with significantly elevated GGT but normal bilirubin -Anticipate paracentesis, US guided APAP level < 5 Hepatitis panel and ANA negative on 1/25/22 Continue supportive care -Metabolic acidosis Assessment & Plan Anion gap acidosis with normal renal function, normal lactate Respiratory acidosis present prior to intubation (now resolved) Ketones in urine - possible alcoholic ketoacidosis / starvation ketosis Continue to monitor renal function, lytes Full code status Assessment & Plan Default status, patient unable to participate in decision making OBJECTIVE: BP 97/77  | Pulse 116  | Temp 37.7 °C (Bladder)  | Resp 16  | Ht 1.79 m  | Wt 86.4 kg  | SpO2 99%  | BMI 26.97 kg/m²  FIO2 (%): 50 % Physical Exam General:  Intubated, sedated, well nourished younger man.  Respiratory effort comfortable on vent. CV:  Tachycardic with regular rhythm, no peripheral edema Respir:  Clear breath sounds, good air entry, no wheezing or crackles GI:  Mild distention, nontender Skin:  Warm, well perfused FIO2 (%): 50 % Type of Mechanical Vent: Hamilton Mechanical Rate: 16 breaths/min Set/Target Tidal Volume: 450 PEEP (cm H2O): 12 cm H2O Inspiratory Time Set: 0.9 second(s)