Age: 75.0
Sex: M
Vaccine: FLUA4, RSV
Symptoms: Computerised tomogram abnormal, Computerised tomogram head normal, Computerised tomogram intestine, Computerised tomogram kidney abnormal, Confusional state
Clinical narrative: On October 7, I woke up confused. My speech was garbled and incoherent. My wife took me to the Emergency room and as symptoms worsened and fever developed I was admitted.  I was unconscious for 5 days (part of this sedated by doctors).  The diagnosis was Acute Encephalopathy. Despite extensive testing (see below) doctors were unable to identify any bacterial, viral, or other cause and therefore diagnosed Aseptic Meningitis.  After release from hospital (7 days including 3 in ICU) needed home care support for 4 weeks.  Due to a seizure during the hospital stay, I have been prescribed levETIRAcetam (KEPPRA) 750 mg twice a day for 3 months and need a neurologist clearance before driving. Below is a detailed report from the hospital:  Name: Patient | PCP:MD  Note From Your Admission on 10/07/23 Discharge Summary by staff at 10/13/23 1030  Hospital Hospitalist Discharge Summary Name/Age/DOB: Patient 75 y.o.   Date of Admission: 10/7/2023 Date of Discharge: 10/13/2023 Discharging Physician: MD Consultants: Infectious disease, Critical care, Neurology  Primary Discharge Diagnoses: Acute encephalopathy Aseptic meningitis Seizure Acute hypoxic respiratory failure Sigmoid colon thickening Essential hypertension Diarrhea Procedure: Lumbar puncture Hospital Course: Acute encephalopathy, aphasia, agitation. resolved -Suspect post ictal given seizure activity, likely caused by aseptic vs viral meningitis -initial MRI with motion artifact, repeat MRI brain with contrast with no stroke, mass or bleed or other enhancement that would assist with diagnosis -Stroke work-up negative including brain MRI -CT abdomen pelvis no source of infection -LP with 9 WBC and elevated protein/glucose, not consistent with bacterial meningoencephalitis but given pleocytosis suspect aseptic or viral cause. -neg WNV, VZV, HSV. neg meningoencephalitis panel PCR as well as cultures -Infectious disease consulted, empiric meningitis coverage and aspiration coverage, DC prior to discharge home -Continue Keppra, given seizure occurred while on 500mg po BID, increased to 1000mg bid however patient noted to be more somnolent with administration dose 750mg po bid reduced 10/11. Will prescribe 3 month supply and refer to neurology on discharge, counseled not to drive until f/u neurology, DMV report -DC statin and ASA given no stroke Acute hypoxic respiratory failure   -intubated for airway protection -extubated and titrated off oxygen  Diarrhea -Cdiff negative  Sigmoid colon thickening -Outpt f/u- colonoscopy -seen on CT -discussed with patient and wife  DVT prophylaxis Medications Reconciled upon Discharge: Discharge Medications  New Medications Details   levETIRAcetam 750 MG tablet Take 1 tablet by mouth 2 times daily for 180 days. aka: KEPPRA      Unchanged Medications Details   losartan 25 mg tablet Take 1 tablet by mouth Daily. aka: COZAAR      Discharge Exam: Temp: 36.8 °C (98.2 °F) Pulse: 63 Resp: 18 BP: 138/75 SpO2: 97 % Radiology results from this hospitalization: Recent Results (from the past 360 hour(s)) CT Perfusion Brain w Contrast Impression IMPRESSION: 1. No acute intracranial findings, no loss of gray-white differentiation. 2. No perfusion asymmetry. 3. No large vessel occlusion or significant stenosis. discussed with Dr. by phone at 10/7/2023 3:05 PM.   Electronically signed by: MD on 10/7/2023 3:05 PM  CT Angio Head Acute Stroke Impression IMPRESSION:  1. No acute intracranial findings, no loss of gray-white differentiation. 2. No perfusion asymmetry. 3. No large vessel occlusion or significant stenosis. discussed with Dr. by phone at 10/7/2023 3:05 PM. Electronically signed by: MD on 10/7/2023 3:05 PM  CT Angio Neck Acute Stroke Impression IMPRESSION:  1. No acute intracranial findings, no loss of gray-white differentiation. 2. No perfusion asymmetry. 3. No large vessel occlusion or significant stenosis. discussed with Dr. by phone at 10/7/2023 3:05 PM. Electronically signed by: MD on 10/7/2023 3:05 PM  CT Head wo Contrast Impression IMPRESSION: 1. No acute intracranial findings, no loss of gray-white differentiation. 2. No perfusion asymmetry. 3. No large vessel occlusion or significant stenosis. discussed with Dr. by phone at 10/7/2023 3:05 PM. Electronically signed by: MD on 10/7/2023 3:05 PM  XR Chest AP Portable Impression IMPRESSION: 1. No acute cardiopulmonary process. Electronically signed by: MD on 10/7/2023 4:10 PM  MRI Brain wo Contrast Impression IMPRESSION:   1. Limited evaluation of the partial exam due to above reason. 2. No gross acute infarct. Severe motion degradation. Electronically signed by: MD on 10/7/2023 8:19 PM  CT Abdomen Pelvis w Contrast Impression IMPRESSION: 1. Diverticulosis of the descending and sigmoid colon without evidence of acute diverticulitis. There is thick appearance of the wall of a short segment of the upper sigmoid colon. This may be related to contraction/nondistention of the sigmoid colon at the time of examination with underlying chronic inflammation or a small neoplasm of the sigmoid colon are not excluded at this level. 2. No evidence of appendicitis, bowel obstruction, nephrolithiasis, hydroureteronephrosis, free air/fluid, or abscess. 3. Mild peripheral atelectasis within the lower lungs, and mild right diaphragmatic elevation. 4. Focal fatty infiltration of the liver adjacent to the falciform ligament. 5. Mild degenerative changes of the spine and sacroiliac joints.   Incidental simple or minimally complex renal cysts (e.g. -10 to 20 HU on CT with or without contrast; or >70 HU on non-contrast CT) , adrenal nodules < 1 cm in size, or adrenal nodules 1-4 cm in size with probably benign imaging characteristics, if described above, do not require specific imaging follow-up based on consensus guidelines. Further lab evaluation could be pursued based on clinical findings. Electronically signed by: MD on 10/8/2023 11:31 AM  XR Chest AP Portable Impression IMPRESSION: Bilateral lower lung atelectasis or aspiration. Continued radiographic follow-up. Electronically signed by: MD on 10/8/2023 10:11 PM  IR Lumbar Puncture Diagnostic Impression IMPRESSION:   Image-guided lumbar puncture, yielding 20 mL of clear fluid. Plan: The patient tolerated the procedure well. The patient was transferred to the recovery area for an hour of observation.     PROCEDURE SUMMARY: - Diagnostic lumbar puncture with fluoroscopic guidance - Additional procedure(s): None PROCEDURE DETAILS: Pre-procedure Consent: Informed consent for the procedure including risks, benefits and alternatives was obtained and time- out was performed prior to the procedure. Preparation: The site was prepared and draped using maximal sterile barrier technique including cutaneous antisepsis. Anesthesia/sedation Level of anesthesia/sedation: No sedation Anesthesia/sedation administered by: Not applicable Total intra-service sedation time (minutes): Not applicable Lumbar puncture The patient was placed in prone position. Local anesthesia was administered. Under image guidance, a spinal needle was advanced into the subarachnoid space using midline interspinous approach. Spinal needle: 22-gauge spinal needle. Interspace level: L4-5 Opening CSF pressure (cm H2O): Not measured Closure The needle was removed and hemostasis was achieved with manual compression. A sterile bandage was applied. Radiation Dose Fluoroscopy time (minutes): 0.1 Reference air kerma (mGy): 1.2 Additional Details Additional description of procedure: None Equipment details: None Specimens removed: None Estimated blood loss (mL): Less than 10 Standardized report: SIR_LPDiagnostic_v3 Attestation   I attest that I was present for the entire procedure. I reviewed the stored images and agree with the report as written. Electronically signed by: MD on 10/10/2023 2:55 PM  XR Chest AP Portable Impression IMPRESSION: Expected positions of the endotracheal and enteric tubes. Electronically signed by: on 10/9/2023 11:07 PM  XR Abdomen Portable Impression IMPRESSION: Expected positions of the endotracheal and enteric tubes. Electronically signed by: on 10/9/2023 11:07 PM  MRI Brain w wo Contrast Impression IMPRESSION: 1. No evidence of acute infarct. 2. Small focus of low SWI signal above the left sylvian fissure measuring 4 mm, which could be related to old blood products. 3. No intracranial mass or abnormal intracranial enhancement. 4. Chronic sinus disease involving the frontal, sphenoid, and maxillary sinuses as well as the ethmoid air cells. 5. Small amount of fluid within the upper pharynx. Small amount of fluid signal within mastoid air cells, left more than right. 6. There is a hypoplastic and nearly aplastic appearance of the medial left transverse sinus, with developmentally small caliber of the lateral left transverse and left sigmoid sinuses as compared to the right. 7. Prominent caliber of the bilateral superior ophthalmic veins. This is a nonspecific finding which can be seen transiently in intubated patients, but also as a result of various other etiologies, including as a result of alterations in intracranial venous drainage pattern and alterations in intracranial   pressure. Consider reassessment on interval follow-up MRI or correlation with conventional angiography if clinically warranted. Electronically signed by: MD on 10/10/2023 10:00 AM  XR Chest AP Portable Impression IMPRESSION: 1. Interval removal of ETT and enteral tube. 2. Bibasilar atelectasis/small pleural effusions. 3. Right upper extremity PICC with tip at the cavoatrial junction. Electronically signed by: MD on 10/13/2023 1:15 PM   Code Status/Advance Directive (Pertinent discussions/declarations): Prior Disposition: Home with Home Health Condition on Discharge: Stable Current Support : Spouse/Partner Support Services Ordered: Home Health Services: Home Health RN and Home Health PT Discharge follow up: MD   Follow up in 1 week(s) For colonoscopy in 1 week after discharge for abnormality seen on CAT scan to rule out colon cancer MD  Follow up in 1 month(s) Seizure follow up Home Health Follow up on 10/14/2023        Close outpatient follow-up recommended: Yes Complex case management needed: Yes Time spent on Discharge and Coordination of post-hospital care: 45 minutes Electronically signed by: MD, 10/18/2023 at 4:45 PM Portions of this chart may have been created with Dragon voice recognition software. Occasional wrong-word or ?sound-alike? substitutions may have occurred due to the inherent limitations of voice recognition software. Please read the chart carefully and recognize, using context, where these substitutions have occurred.