Age: 63.0
Sex: M
Vaccine: COVID19-2
Symptoms: Malnutrition, Mental status changes, Nitrite urine present, Oxygen saturation decreased, PCO2 increased
Clinical narrative: Patient is a 64 y.o. male patient of MD with history of COPD, CHF with LVEF 45 to 50%, seizure disorder, A-fib on Xarelto, bladder cancer status post cystectomy with ileal conduit, ongoing tobacco dependence presented to Hospital with AMS, hypoxemia.   Encephalopathy- improving Delirium Agitation Per wife this has been ongoing since his recent admission. Suspect secondary to COVID-19 versus other infectious etiology Placed no AMA MRI brain during recent hospitalization was negative for any acute findings. Afebrile, vital stable. VBG pH 7.4, PCO2 52, PO2<30. Sodium 134, potassium 3.3, lactic acid 0.8, WBC 8.8, hemoglobin 11.8. Troponin 16, 16. CT head, CT cervical spine with no acute injuries. CT pulmonary angiographic study showed bilateral pleural effusions, infiltrative changes in bilateral lower lobes as well as atelectasis or infiltrative process involving the lateral segment of the right middle lobe which is new since previous imaging with probably reactive lymph nodes in mediastinum, hilar and subcarinal location which are new. EKG with no acute ST-T changes. UA positive for nitrite, urine culture with 3 more morphotypes suggesting possible contamination. Prelim blood cultures negative 5 days Initiated on broad-spectrum antibiotics with vancomycin, cefepime, then DC'd as pro-calcitonin 0.13.  Fall precautions. Consulted behavioral health as patient noted to be agitated, trying to get out of bed and leave the hospital. 11/23?recommendation for olanzapine 2.5 mg twice a day.  Could increase dose if needed otherwise would start with increasing evening dose to 5 mg if needed.  Monitor thrombocytopenia which could be a side effect of valproic acid.  Platelet count up to 192 on 11/27 Evaluated by PT/OT on 11/27.  Updated recommendations for 2-3 days.  Case management setting up home health care with spouse to transport home on discharge Acute hypoxemic respiratory failure Abnormal CT COPD VBG, chest imaging as above. Continue broad-spectrum antibiotics, steroids. Had to be increased to 5 L of oxygen via NC wean oxygen as able. Pulmonary consulted given abnormal CT chest findings. Appreciate input. Recommend to continue Trelegy and albuterol at home, Dulera and Spiriva whilst inpatient. Recommend follow-up CT chest in 6 to 8 weeks to ensure resolution of mediastinal lymphadenopathy. Was stable on RA with one desat. Home O2 eval ordered.  Qualified for 2 L nasal cannula continuously on 11/28   Bradycardia resolving On 11/22, patient was noted to be bradycardic on telemetry EKG with sinus bradycardia Avoid rate lowering medications Monitor   Covid-19 virus Infection Date of onset of symptoms: Unsure Symptoms present on admission: Yes Date of covid positive test: 11/12 Imaging: CT pulmonary angiogram. Results as above. Oxygen requirements on admission: Yes 4 L nasal cannula. Current oxygen requirements:  RA < 2 L nasal cannula. Medical therapy: steroids Consultants following: ID. Anticipated special isolation end date: 11/22   GERD Resumed home Tums as needed   History of hospital delirium Likely secondary to multiple etiologies, such as pneumonia from COVID versus other bacterial, viral etiology, COVID encephalopathy, secondary to hypoxemia, severe protein calorie malnutrition. Seen by behavioral health team during recent hospitalization. Was discharged home with olanzapine 2.5 mg twice daily. Continue olanzapine, will use Haldol 1 mg every 6 hours as needed. BH consulted as above.  Appreciate input. Nonischemic cardiomyopathy Chronic HFrEF, POA Nonobstructive coronary artery disease LHC 2014  LVEF of 45-50% 09/18  Continue home aspirin and statin, not on any beta-blocker due to bradycardia.   Bladder cancer s/p radical cystoprostatectomy 3/2023 Diagnosed- 10/2022, follows with Dr. Pathology showed high grad erothelial carcinoma with squamous differentiation, muscularis propria involved by invasvie carcinoma  Unable to tolerate chemo, no further neoadjuvant chemotherapy recommended per urology S/p radical cystoprostatectomy 3/2023 Currently on tecentriq q28 days, most recently treated 10/13 No plans for inpatient treatment  Repeat surveillance scans per oncology team during inpatient stay, MRI brain negative.   Seizure disorder Continue home Depakote 500 3 times daily   Paroxysmal atrial fibrillation, POA Continue Eliquis   Severe protein calorie malnutrition, POA BMI- 18 Nutrition consulted.  Appreciate input.   Hypokalemia K 3.4 Klor con ordered 11/27.  Potassium up to 4.1 on day of discharge   Patient seen and examined.  Denies any major complaints.  Was on room air at the time and had been tolerating.  Had desaturation after evaluation.  Home O2 evaluation ordered.  Qualified for 2 L nasal cannula continuously.  Case management assist with setting up home O2