Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal pain, Agitation, Amnesia, Anal incontinence, Anion gap
Clinical narrative: ED NOTE 67 y.o. female with a history of type 2 diabetes mellitus and hypertension on insulin and baby aspirin who presents to the emergency department stabilization room 1 with daughter for evaluation of weakness. The patient's daughter states that for the last two weeks the patient has been increasingly forgetful and weak. The daughter also reports that the patient has been complaining of abdominal pain, knee pain, and generalized pain throughout her body. Today the patient was having difficulty standing due to weakness as well as decreased oral intake. The patient was also having increased fatigue. The patient arrives to the ED nonverbal and incontinent of stool. The patient is vitally stable here and has a blood sugar of 387.   PROGRESS NOTE 1/23/2022 Acute metabolic Encephalopathy 2/2 COVID Hospital related encephalopathy Possible seizure with post-ictal state - now resolved Presented w/ concerns for encephalopathy. Family noted confusion and concerns starting roughly around 2am on 1/15 after pt had a fall from bed a couple days prior. Per pt's daughter, two weeks PTA pt had sudden acute short term memory loss but was able to walk, talk and eat. However, 2 days after her fall at home, she was no longer talking, walking or eating.    Suspect presentation 2/2 COVID encephalopathy with possible non-convulsive seizure w/ post-ictal state   Workup to date: Bacterial infection appears unlikely given current w/u. CXR without abnormalities. UA non-infectious. Head CT unremarkable. Lactate WNL. B12/Folate WNL. MRI brain without evidence of stroke, although was limited 2/2 patient agitation.  Per prior notes on 1/17 patient appeared more alert , though still nonverbal, but moving and opening eyes. Dried blood was noted in mouth and lower jaw loose tooth, question if patient had a seizure when she fell PTA   By 1/19, she was much improved. Awake, talking and eating full meals.  She was alert to person and hospital.     1/20 - 1/22: much improved from admission. She is routinely alert to person, hospital and year.  Intermittent confusion related to hospital encephalopathy - is readily redirectable and reoriented if interpreter is readily available.  Confusion quickly worsens if interpreter not available (this is challenge as can take 30-40min to get interpeter).   I suspect her confusion is 2/2 COVID encephalopathy and further exacerbated by being in hospital setting w/ limited access to speaking individual. Neurology signed off 1/19. Recs:             * EEG with abnormal activity, supportive of epilepsy             * LP 1/17: CSF studies: HSV, syphilis, cell counts, culture, cytology neg             * Keppra started 1/17, cont (given concern for seizure in setting of COVID+)                         - will need outpt f/u with Dr. to determine outpt repeat EEG and how long she should remain on keppra             * MRI limited 2/2 agitation but no evidence of infarct or tumors  Generalized weakness COVID-19 infection Weakness likely 2/2 COVID. Incidentally found COVID + at admit screening on 1/15.. CXR without infiltrates. O2 sats stable on room air, although tachycardic. Do not suspect PE at this time.  - Supplemental O2 prn -- currently on room air - Full barrier precautions - Not a bari/toci candidate given room air status - Lovenox 1 MG/KG BID per guidelines - PT/OT - may need TCU, however will need to discuss w/ family. May not be best place for her given confusion and language barrier - 1/20: dimer improving but still > 1, cont therapeutic lovenox             - dimer check on 1/23   Hyponatremia, resolved Resovled w/ IVF hydration     Type 2 diabetes mellitus Diabetic peripheral neuropathy PTA Metformin, 70/30 18 U BID. On admission, BG 350s with anion gap of 11 and bicarb of 19, does not meet DKA criteria. Now better controlled. Hgba1C 10.5.  TODAY: eating much better since 1/19, gradually titrate insulin - increase lantus to 15units qhs - Medium SSI - Hold PTA Metformin  Hypertension Elevated BP here. PTA Lisinopril 20 MG daily.  - prn hydralazine for SBP >170  - continue PTA Lisinopril   Depression PTA Cymbalta 30 MG daily - Continue Cymbalta   Hypokalemia - resolved Hypomagnesemia - resolved IV fell out. IV team unable to place new line and pt not wanting IV. To help support calming, comfortable environment will go without IV for now to help her encephalopathy. - d/c K/Mg protocol 1/20 as pt not tolerating IV - lytes normalized after PO replacement - BMP and Mg daily