Age: 95.0
Sex: M
Vaccine: COVID19
Symptoms: Hypersomnia, Hypotension, Lactic acidosis, Magnetic resonance imaging abnormal, Malnutrition
Clinical narrative: Admit date: 2/19/2024  Discharge date:  2/27/2024  Admitting Physician:  DO   Attending Physician at the Time of Discharge: MD  Primary Care Physician:  NP Reason for Admission:  98 YO female with h/o afib, HTN, HLD, hx CVA with subsequent left sided hemiparesis, HFpEF, T2DM, CKD 3, normocytic anemia, hypothyroidism, and dementia presenting with altered mental status. Patient is accompanied by her daughter, and daughter in law who are able to provide history. Her daughter reports she visited her mother at nursing facility, who found her to be in altered mental status.  Patient was noted to have acute hypernatremia and worsening uremia in the setting of acute on chronic kidney injury as well as possible urinary tract infection..    Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  Hypersomnolence in the setting of dementia with recent right MCA stroke, recent COVID-19 infection and recovering from acute hypernatremia and uremia in the setting of likely urinary tract infection -treating acute issues as below -we will avoid any medication that has potential to sedate patient -improved alertness on trial of low-dose Ritalin twice daily at 8:00 a.m. and 2:00 p.m.  Sepsis secondary to UTI +/- bacteremia -completed 7 days of IV ceftriaxone covering  urine culture growing 2 different strains of E coli -indwelling foley catheter in place for chronic urinary retention -30 cc/kg fluids given in ED resolved hypotension -venous lactate has normalized with additional fluid bolus -1 out of 3 sets of blood cultures positive for Staph epidermidis and viridans strep sensitive to Cephalosporins; ID feels this is most likely contaminant and that 7 days of Cephalosporin should be adequate to cover the Strep viridans in this context  Afib RVR on admission, resolved, ventricular rate is controlled now -is not anticoagulated at home, CHADVASC2 score of 9 with 12% annual stroke risk without anticoagulation, also history of bilateral PE, family does not want to anticoagulate at this time, we discussed with daughter and decision remains the same -restarted on home beta-blocker -also given loading doses of digoxin, if rate remains difficult to control could consider maintenance dose -continue cardiac telemetry monitoring   AKI on CKD 3a resolved -giving fluid boluses intermittently -minimize nephrotoxic agents -minimize hypotension, will likely not restart home furosemide  Acute Hypernatremia - resolved with D5 water -encourage oral intake with encouraging AFC to track patient's oral intake daily on discharge with goal of 1.5-2 L daily -continue to monitor with the at least every other day labs  Left lower lobe atelectasis No clinical evidence of pneumonia  Chronic dysphagia -speech therapy consulted - recommendation-  SLP recommending NDD II/IDDSI 5 with thin liquids, meds whole with puree or thin liquids, strict aspiration precautions  Chronic bilateral PE  -not on anticoagulation at home due to comorbid acute stroke at time of pulmonary emboli which were thought to be chronic -family not interested in blood thinner at this time   Hx CVA -history of acute to subacute infarct of right parietal lobe, posterior right insula, and a small portion of the superior medial right temporal lobe noted on MRI 1/11/24 -subsequent left sided hemiparesis, Q2 turns, bedrest  -continue ASA 81 daily for now -with history of atrial fibrillation patient is annual stroke risk off of anticoagulation is 12% per year, family not interested in blood thinner at this time  HFpEF -most recent echo 1/11/24 EF 55-60% -holding home lasix in setting of AKI and lactic acidosis, we will consider not restarting  T2DM - consider increasing Lantus from 8 to 10 units at bedtime - hold prandial Humalog with inconsistent oral intake, will make minor adjustments on discharge -continue Humalog sliding scale -most recent A1c 8.1% on 1/11/24  Hypothyroidism -continue home synthroid once able to tolerate oral intake  Dementia -continue home namenda but moved to nighttime per family presence   Severe protein calorie malnutrition with poor appetite -dietitian consulted for supplements -we will continue Megace with mirtazapine contraindicated with dementia and stroke history due to its sedating quality -calorie counts, markedly improved oral intake  Left periprosthetic supracondylar femur fracture on 01/10/2024 -treated conservatively by Orthopedic surgery with nonweightbearing status initially now with recommendations to wear a brace when ambulating  Issues Requiring Follow Up: (Who, what, when, and how communicated?)  Patient transition to hospice owned by patient's granddaughter.  Patient to stay on Ritalin and Megace as she is responded very well to these. Discharged to Hospice.