Age: 90.0
Sex: F
Vaccine: COVID19
Symptoms: Condition aggravated, Confusional state, Contusion, Culture, Delirium
Clinical narrative: 90 y/o male with PMH of afib (no anticoag), Parkinson's, HTN, T2DM, TIA, and chronic pneumothorax who wasrecently diagnosed with COVID and presented from SNF to Hospital after a fall. Noted to have large Rt sided pneumothorax (known chronic pneumothorax) and transferred for further evaluation, s/p chest tube placement in ED. Course c/b delirium.  #  AMS (altered mental status) Per collateral from Geriatrics, HCP, and facility, pt frail but oriented and sometimes forgetul at baseline, requires assistance with ADL and is dependent for iADL.  Care everywhere notes document prior history of TIA. He was diagnosed with COVID ~9/1 and facility notes increased confusion since that time. Pt did have headstrike, but Head CT did not show any acute abnormality. On initial presentation, pt was unable to follow commands for full neuro exam but no clear focal deficits.  consulted. Mental status subsequently improved, more conversant. Suspected pt was acutely delirious on top of poor and fragile substrate (Parkinson's, likely some dementia) 2/2 acute illness, chest tube, missing Sinemet, new environment, missed sleep, etc. Treated pain from chest tube, continued Sinemet per #Parkinson's, delirium precautions. For agitation, tried verbal redirection, then started low dose Trazodone nightly with improvement. However this was discontinued due to somnolence. Delirium precautions maintained.   #  COVID-19 Patient was fully vaccinated at his SNF. He developed COVID 3-4 days prior to admission (~9/1) with increased confusion and new fall. Staff at facility note that he has not had hypoxia or fevers prior to admission. CT chest at OSH with mod-large R sided hydropneumthorax, opacities in LUL, R upper, middle lobes - may represent atelectasis vs inflam vs infection. As below he underwent chest tube placement in ED for pneumothorax. He does not appear SOB and no cough on exam, and now on RA. COVID cycle threshold 22. Repeat chest CT with improved hydropneumothorax and left sided opacities, infection vs inflammation. Lower suspicion for bacterial process - no fever, no leukocytosis and procal 0.1, so no antibiotics given. Given 5 days remdesivir (9/5-9/9). No O2 requirements, so no dexamethasone indicated. Repeat PCR on 9/8 positive with CT < 30, so continued precautions.  Precautions discontinued as of 9/21 and considered "COVID recovered".     #  Hydropneumothorax Notes in Care Everywhere from 11/2019 mention traumatic hydropneumothorax. CT Chest this admission with moderate to large R hydropneumothorax. There was concern in ED for mild hypoxia and increased size of hydropneumothorax and they proceeded with chest tube placement in ED on 9/5 with output of 1,500cc clear serous fluid; exudative effusion per Light's criteria. CXR with decrease in size of R pneumothorax and slight kinking of the R basilar pigtail chest tube. Thoracics did not feel any surgery was indicated given long standing nature of this but will follow for assistance with chest tube management. Repeat chest CT 9/6 with decrease, now small R hydropneumothorax, partial reexpansion of right lung, unchanged atelectasis in right middle and lower lobe, LUL opacities.  Consider contribution of COVID to increased size. Continued chest to -30cm suction until <200cc output in 24 hrs, then transitioned to water seal and then removed 9/10 without issue. CXR after removal showed small R pleural effusion Analgesia with standing Tylenol + lidocaine patches with PRN oxycodone. Pleural fluid culture without growth.   #  Fall at home, initial encounter Patient had unwitnessed fall at his SNF about 3 days after new COVID diagnosis. He was noted to have increased confusion after COVID diagnosis. He had head strike with bruising behind left ear. Head CT without acute abnormality, cervical spine CT negative. He was previously on Florinef but no longer. Given propensity of patients with Parkinson's to have autonomic instability and orthostasis and likely prior history of such since he was on Florinef, suspect orthostasis and weakness from infection. Mild troponin elevation, stable. No ECG unloaded to MUSE. Also with some hypoxia and increasing pneumothorax so possible that this contributed to fall. Has DM on insulin and no documented hypoglycemia.  EKG, tele without cardiac events. Tx per #COVID. Blood glucose mgmt per #DM. PT, OT evaluated and recommend sub acute rehab.    #  DM (diabetes mellitus) On glargine 37 units and metformin 500 mg BID at home. Held metformin, reduced dose of glargine during admission, and started ISS. Asymptomatic hypogylcemia during admission on 9/8, so downtitrated dose. On discharge, he is on Lantus/glargine 6 units per night and sliding scale aspart insulin TID with meals.      #  Parkinsons Patient at baseline is A&Ox3), ambulates independently. Here with marked change from baseline with delirium and significant tremor R>L UE + cogwheeling. Anticipate that he has missed several Sinemet doses given acute hospitalization, transfer from OSH ED; resumed on admission, 9/5, and continued. Continues to have cogwheeling. Geriatrics consulted, rest per #AMS.