Age: 69.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Hypotension, Intensive care, Ischaemia, Lactic acidosis, Leukocytosis
Clinical narrative: 69 year old male with a PMH of hypertension and T2DM who was admitted on 3/12/2021 for lactic acidosis, hyperglycemia (to 580s), RUE weakness/dysarthria/weakness (now resolved), and septic shock of unknown etiology.   Outside Hospital: Seen at ED where a stroke code was called for headache, RUE weakness, dysarthria with a CT and CTA that were negative for any acute changes. He he was febrile to 102.2, tachycardic to 130s, hypotensive with pressures in the 80s systolic unresponsive to fluids, leukocytosis to 15 and lactate of 3.5. He was started on vancomycin, ceftriaxone, ampicillin, acyclovir, and dexamethasone. Additional workup including an LP, UA, and CXR were all unremarkable. He was transferred here due to a lack of beds. Of note, the patient received his second COVID-19 vaccine dose on 3/10 and had been febrile since the morning of 3/11.   Hospital ICU: Patient is hemodynamically stable and has been fully weaned off pressor support. His hyperglycemia is decreasing satisfactorily to insulin and is receiving IVF. Repeat lactate for PM of 3/12 and workup for TIA initiated.      Assessment and plan :   69 year old male with a PMH of hypertension and T2DM who was admitted on 3/12/2021 for lactic acidosis, hyperglycemia (to 580s), RUE weakness/dysarthria/weakness (now resolved), and septic shock of unknown etiology requiring vasopressors, antibiotics, and TIA workup. I have personally reviewed the daily labs, imaging studies, cultures and discussed the case with referring physician and consulting physicians.  My assessment and plan by system for this patient is as follows:   Neurology/Psychiatry:  # RUE Weakness, headache, dysarthria Presented to Hospital with RUE, headache, and dysarthria with negative CT and CTA. The patient has a known hx of diabetes and hypertension with a recent elevated A1c. His hypotension as a result of sepsis may have revealed territories in his cerebrum particularly affected by his likely vascular disease. Will initiate TIA workup. Pending results, will consider Neurology Consult. Plan: - ASA 81 mg PO daily - Echocardiogram - Fasting lipid panel - Bilateral carotid artery ultrasound   Cardiovascular: # Hemodynamics, Rhythm, Ischemia # Septic Shock Weaned off NE, still on Vasopressin 2.4. Monitor shows NSR in the 70s. Has now been weaned off vasopressors. Plan: - Weaned off pressors   # History of hypertension Plan: - HOLD PTA lisinopril   Pulmonary/Ventilator Management:  # Airway, Oxygenation, Ventilation, Mechanics: No airway in place. Unlabored breathing on room air without assistance with sats in mid-90s. Plan: - Monitor   GI and Nutrition :  # BMs/Gas/Feedings: Reports having diarrhea. No enteral feeds. Plan - Monitor electrolytes   Renal/Fluids/Electrolytes:  # Electrolytes, Acid/Base, Volume Patient is septic and requiring pressors. He is also having diarrhea, so monitor electrolytes, creatinine, UOP. Glucose responding to insulin, most recently 159. If this afternoon's lactate and creatinine normalize this afternoon 3/12/21 and the patient continues to eat/drink ok (which he has been), then we can turn off his IVF. Plan: - HOLD Metformin given elevated creatinine and risk of metabolic acidosis - Lactated Ringers at 75 mL/hr continuous - Trend BMP - Monitor UOP - Venous Blood Gas - Electrolyte replacement per ICU protocols - Generally avoid nephrotoxic agents such as NSAID, IV contrast unless specifically required - Adjust medications as needed for renal clearance - Follow I/O's as appropriate   Infectious Disease:  # Septic Shock # Leukocytosis # Lactic Acidosis # Recent Covid-19 Vaccine Patient was tachycardic to the 130s, hypotensive with systolic pressures in the 80s, and febrile to 102.2 F. Worked up extensively at outside hospital with the following perfomed: Negative CT/CTA, unremarkable lumbar puncture, unremarkable CXR, and unremarkable UA. His pressures were not fluid responsive at that time, so we will continue some further workup here as below. In addition, there remains the possibility that this patient's current status may be a result of the Covid-19 vaccine and cannot be ruled out given its temporal relationship to his presentation. Will document this potential reaction with the Department of Health. Patient's most recent lactate returned at 6.5 and likely reflects his critical illness in combination with decreased clearance (given that his creatinine was 1.7, unclear baseline).    Plan: - MRSA Swab, nares - Stool Ova and Parasite - CSF Culture - CSF HSV (from outside hospital, pending) - Continue piperacillin-taxobactam - Trend procalcitonin - Trend lactate - Report possible Covid-19 reaction with DH   Endocrine:  # Hyperglycemia # Recent Diagnosis of T2 DM not on Insulin Was found to be hyperglycemic in the high-500s on arrival. At least part of his hyperglycemia is a result of receiving dexamethasone at the hospital. However, his most recent A1c on 3/12 was 8.8 and his diagnosis of T2DM is recent. Plan - Diabetic diet - Nutrition consult - Insulin bolus 5 U - ICU insulin protocol with goal of BG <180 - HOLD PTA metformin   Hematology/Oncology:  # Hgb, Platelets Within normal limits. - Monitor as appropriate   # Leukocytosis Leukocytosis to 15.4 here. Plan as above. Plan - Trend CBC   MSKL/Rheum: # Right Shoulder Pain Reports having some right shoulder pain over the last few weeks, exacerbated by shoveling snow. Pain with right arm abduction. Pain is greater in arm and forearm than shoulder itself. Plan: - Tylenol PRN for pain - Outpatient f/u as needed.   IV/Access:  1. Venous access - Left brachial PICC, left wrist PIV 2. Arterial access - None   ICU Prophylaxis:  1. DVT: Hep Subq/ LMWH/mechanical 2. VAP: Not applicable 3. Stress Ulcer: Not indicated 4. Restraints: Not indicated at this time 5. Wound care - per unit routine  6. Feeding - Diabetic Diet 7. Family Update: Updated wife who was at bedside on AM 3/12/21. 8. Disposition - ICU pending further workup, treatment, and continuation of vasopressors.