Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: Mental status changes, Oedema peripheral, Osteoarthritis, Pulmonary congestion, Pyrexia
Clinical narrative: Patient is a 87 y.o. male patient of DO with history of Hypertension, CKD, Anemia, Diverticulitis, GI bleed, Prostate cancer, Alzheimer's dementia, presented to Medical Center with with AMS found to have SDH with brain compression. Hospitalization complicated by GI bleed UTI.   Covid-19 Virus Infection Onset ~ 9/3, + Test on 9/4/23  Sx Fatigue, fever Imaging: CXR clear lungs PCXR 9/17-Increased lung markings bilaterally, may be related to minimal pulmonary vascular congestion versus bronchitis. Baseline on RA, then required 2L NC but back on room air   Medical therapy: Decadron, Remdesivir  Consultants following: ID E-consult, not a candidate for Paxlovid, discussed with ID  Anticipated special isolation end date: 9/15/2023 No longer symptomatic  See Quick note 9/15   Subdural Hematoma Brain Compression, POA  CT Head 9/5 with Acute on Subacute 14 mm SDH with mass effect on L cerebral hemisphere and minimal 2mm MLS NSGY assessed and recs L SDH evacuation-family decline Repeat CT Head 9/6 stable   Neuro checks q2h neuro checks  Family fearful of worsening neurologic status after surgery or physical decline Neurosurgery now signed off Palliative care consulted  Nutrition consulted-boost plus 1 x per day  PT evaluated patient and difficult to have him progress due to inability to follow commands Discussed PT evaluation with family, continue to want to work toward rehabilitation    GIB Chronic anemia Plan hemoglobin 9.9 (11/23/2019) -- > 10.5 on admission CTA dissection negative for active GI hemorrhage INR 1.3  Noted as of active bleed Hemoglobin stable, 9.5, Hgb stable at 9.2, 8.2  9/11, 8 9/12, 8.4 9/13, 8.3  9/15, 8.7  9/16 Monitor for any worsening, given COVID-19/oxygen dependence not ideal for endoscopy at this time Patient is a specific religion per palliative care documentation  Dark bowel movement 9/9 per nursing, will monitor for now but if he has another we will consult GI  Smear of blood with wiping, likely hemorrhoids Heme consulted-will place blood conservation orders will order SPEP, IFX given patient age, GFR and anemia F/u GI outpt F/u Heme Outpt  UTI Leukocytosis  WBC elevated 11K 9/13; 16K 9/15, 12K 9/16 Likely secondary to steroids, no fevers, no longer requiring oxygen AAS and U/A, Urine cx- E coli with sensitivities pending. Bladder scan scheduled for SNF Follow per SNF physician pending U/A cx.  Start empiric Keflex 250 BID x 7 days starting 9/17 per discussion with nursing at SNF and faxed updated AVS 9/16 AM   Edema Rt hand Xray -Nonspecific soft tissue swelling along the dorsal aspect of the hand.  This is nonspecific.  Cellulitis is in the differential.No acute bone or joint abnormality.  Interphalangeal joint osteoarthritis is noted. Keep elevated  Heat ordered prn Follow per SNF physician   Acute metabolic encephalopathy Dementia, alzheimer's  Likely due to SDH, COVID superimposed on underlying dementia At baseline dependent for most ADLs SDH and COVID mgmt as above Palliative following for goals of care At this time goals seem to be life-prolonging, rehabilitative Discussed limitations with family briefly Palliative consulted Nutrition consulted-boost plus 2 x per day    Abnormal CT kidney CTA revealed 2 cm heterogenously enhancing lesion in the posterior aspect of the right kidney new from 2019 concerning for renal neoplasm, 1.5 cm possible enhancing lesion posterior aspect left kidney likely unchanged from 2019 Plan arrange outpatient renal protocol MRI per PCP   Thyroid nodule CT revealed 3.2 cm right thyroid nodule Arrange outpatient thyroid ultrasound per PCP   Essential hypertension Benign, controlled Holding amlodipine Electrolyte abnormalities- Resolved CKD stage III Sodium 146 9/11, 9/12, 144 9/13 bicarb 20  9/11 Creatinine 1.92 (11/23/2019) -- > 1.24 on admission Cr rising to 1.44, 1.2  9/11, 9/12, 1.3 9/15 Started MIVF bolus, bladder scan ordered Avoid NSAIDs, IV Dye