Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Critical illness, Culture, Diverticulitis, Epiploic appendagitis, Fibrin D dimer increased
Clinical narrative: Hospitalized (1.11.22 - still admitted currently); COVID-19 positive (1.11.22); Fully vaccinated -moderna x2 1/11/22 H&P:   MICU HISTORY & PHYSICAL   CHIEF COMPLAINT: Septic shock   Length of Stay: 0 days   Assessment/Plan    ASSESSMENT / PLAN:  Assessment and Plan * Septic shock Assessment & Plan Source unclear - pna vs. Diverticulitis vs. Other vs. Non-infectious --appreciate general surgery input - doubtful   Volume resuscitate NE/Vaso for MAP > 65 Pan cx; film array, strep pneumo, legionella ag Empiric meropenem/vanco/azithro   SARS-CoV-2 positive Overview SARS-COV-2 +PCR 1/11/2022 -on RA -nodular consolidation LLL - possible aspiration vs. Developing bronchopneumonia   Vaccinated March 3/2021 - moderna x 2 doses - no booster   Assessment & Plan Remdesivir 1/11 -  No glucocorticoids as on RA   Check baseline CRP, D-dimer   Cerebral palsy Assessment & Plan Resides in AFC Right sided hemiparesis Nonverbal Guardian   Seizure disorder Assessment & Plan On 3 anti-epileptic medications and has vagus nerve stimulator Labeled as intractable localization-related epilepsy Last seen in neurology clinic 9/21   History of hypertension Assessment & Plan On Lisinopril and Mobic as an outpatient Currently on hold   Type 2 diabetes mellitus Assessment & Plan On 3 oral agents including metformin - all on hold NPO for now - corrective insulin as indicated  Discussion   This patient is critically ill and is requiring active support and intensive surveillance to prevent life threatening clinical deterioration.  I spent a total of  80  minutes in the evaluation and management of this patient excluding all procedures.  Subjective    HISTORIES: Patient is a 63 y/oM with pmHx CP, seizure disorder, hypertension, hyperlipidemia, GERD admitted to the MICU 1/11 from ED due to septic shock. Patient presented from home due to AMS with notable fever, tachycardia, and hypotension.  Labs confirmed LA 3.6, hemoglobin 7.9, COVID + PCR.  CT thorax/abdomen/pelvis with LLL infiltrate, small bowel diverticulitis vvs acute epiploic appendagitis.  He was given 2L IVF, cultures obtained, and he was given a dose of vancomycin and cefoxitin.  General surgery consulted and felt the abdominal findings did not account for the acute septic shock, as his exam was benign.  Despite IVF, he remained hypotensive and required NE and Vaso, therefore was transferred to the ICU for ongoing care.   Review of Systems  Unable to perform ROS: Patient nonverbal   OBJECTIVE: BP 130/56  | Pulse 74  | Temp 36.2 °C (Rectal)  | Resp 21  | Wt 73.8 kg  | SpO2 99%  | BMI 26.26 kg/m²    SOFA Score            SOFA:    4.3    SOFA RESPIRATORY:   0   SOFA COAGULATION:   0.1   SOFA LIVER (BILIRUBIN):   0.1   SOFA CARDIOVASCULAR:   4   SOFA CENTRAL NERVOUS SYSTEM:   0   SOFA RENAL:   0.1   Physical Exam Constitutional:      Appearance: He is ill-appearing.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Cardiovascular:     Rate and Rhythm: Normal rate.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.  Skin:    General: Skin is warm.     Comments: Pressure wounds on both hips and right sacral region Erythema of groin and scrotum  Neurological:     Mental Status: He is alert. Mental status is at baseline.     Comments: Right hemiparesis    1/15/22 Infectious Disease Consult note: Inpatient Consult to Infectious Diseases  Consultation Note   REASON FOR CONSULT: Multiple sources of infection   ASSESSMENT / PLAN:   MSSA bacteremia Assessment & Plan MSSA bacteremia Most likely secondary to pneumonia. MSSA is not a gut commensal and I would not expect MSSA bacteremia as a result of diverticulitis-like process. Left lower extremity wound shows no evidence of infection. First positive blood culture is from 1/11 Repeat blood cultures TTE from 1/12 was technically difficult study, no obvious vegetations   -Continue Vancomycin          Goal trough 10-20          Monitor daily BMP/CMP for nephrotoxicity -Repeat blood cultures now (ordered) -No need for TEE -Pt will require outpatient IV antibiotics, but do not order PICC line until source control achieved and repeat blood cultures negative at 72hrs -Will require weekly CMP, CBC while on home IV antibiotics -Will require follow up in the Infectious Disease clinic   Polymicrobial bacteremia Assessment & Plan MSSA, MR-S pettenkoferi, MR-S haemolyticus, S epidermidis Source of these bacteria is not clear, question polymicrobial pneumonia vs soft tissue infection of pressure ulcers Very low suspicion for GI infection as etiology of multiple Staph spp in blood   -Continue Vancomycin          Goal trough 10-20          Monitor daily BMP/CMP for nephrotoxicity -Repeat blood cultures -Okay to stop Ceftriaxone and Metronidazole   SARS-CoV-2 positive Overview SARS-COV-2 +PCR 1/11/2022 Vaccinated March 3/2021 - moderna x 2 doses - no booster Not requiring oxygen   Assessment & Plan -Completing Remdesivir x 5d   Thank you for allowing me to participate in this case Infectious Diseases Staff Physician   SUBJECTIVE: Patient is a 63 y.o. male with cerebral palsy and seizure disorder He lives in adult foster care History obtained from EMR as patient is nonverbal   He was admitted on 1/11 after presenting with altered mental status and fever He was also noted to have tachycardia and low blood pressure   Tachycardic and slightly hypotensive, but afebrile on arrival Arrival labs revealed WBC of 12.60 COVID-19 PCR positive on arrival Two sets of peripheral blood cultures from 1/11 are positive One set is showing MSSA, S hominis and [MR]S haemolyticus The second is showing S haemolyticus and S epidermidis Strep and Legionella antigens negative on 1/12 Film array negative for other pathogens (save COVID) on 1/12 MRSA screen negative on 1/12 Two sets of blood cultures from 1/12 [MR]S pettenkoferi Two sets of blood cultures from 1/14 are negative in process CT chest/abdomen/pelvis from 1/11 reveals nodular infiltrates in the left lower lobe, diverticulitis vs epiploic appendagitis Currently on day 4 of Ceftriaxone, Vancomycin and Metronidazole Also received several doses of Azithromycin on arrival  OBJECTIVE:   Vitals:   01/15/22 1840 BP:   Pulse:   Resp: 26 Temp: 37.8 °C Weight:   Height:     Physical Exam Constitutional:      Comments: Chronically ill-appearing, no acute distress  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Comments: Peripheral perfusion intact, no peripheral edema Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No deformity.  Skin:    Findings: No rash.     Comments: Has a pressure ulcer on lateral aspect of left ankle; no significant drainage, no surrounding erythema. Wound base is pink, healthy.  Neurological:     Comments: Patient does attempt to answer some questions: some answers are a single, unintelligible word and sometimes he provides an affirmative response.    1/17/22 - General Medicine progress note: CHIEF COMPLAINT: Septic shock   ASSESSMENT / PLAN: Sepsis, resolved   Pneumonia Vancomycin ID on consult   Colitis ID on consult   Wounds on buttocks, ankle, toes and other areas Wound on consult   Anemia Fecal occult blood test negative Likely secondary to chronic illness Status post 2 unit PRBC this visit Monitor hemoglobin   COVID Remdesivir On room air No need for Decadron   History of cerebral palsy History of seizures History of right-sided paralysis Guardian Guardian planning for change of code status to hospice Awaiting court hearing, 1/19   Continue therapy as above.  Await court hearing.  Subjective  Degree of protein calorie malnutrition (if present):    SUBJECTIVE: Patient lying in bed, comfortable, seen after being cleaned by staff.  No acute events overnight.  Not in any distress.   Review of Systems Unable to perform ROS: patient nonverbal   OBJECTIVE: BP 126/67  | Pulse 91  | Temp 36.6 °C (Axillary)  | Resp 22  | Ht 1.524 m  | Wt 61.8 kg  | SpO2 95%  | BMI 26.61 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is not diaphoretic.  HENT:     Head: Atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No deformity.     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert.     Comments: Unable to respond verbally, consistently  Psychiatric:        Behavior: Behavior normal.