Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Liver function test normal, Mental status changes, Metabolic encephalopathy, Neurological examination abnormal, Normocytic anaemia
Clinical narrative: Hospitalized (1.13.22 - still admitted currently); COVID-19 positive (1.13.22); Fully vaccinated -moderna x2 1/13/22 H&P: Attestation signed by doctor at 1/13/2022  2:34 PM I have personally interviewed and examined the patient on 1/13/2022. I agree with the documented findings and plan of care in his/her note.   Brief Exam:  General:  Alert, in no acute distress Cardio:  Regular rate and rhythm Pulm:  No respiratory distress, clear GI:  Soft, nontender Ext:  No lower extremity edema Neuro:  Alert and oriented x3     Brief history and medical decision making:  Patient is a 75-year-old female who presented to the emergency department with altered mental status.  She was found to be COVID positive with a urinary tract infection.  She was started on Rocephin.  Patient with improvement as she is now alert and oriented.  Will continue to monitor.  CHIEF COMPLAINT: Toxic metabolic encephalopathy     Assessment/Plan    ASSESSMENT / PLAN: Toxic metabolic encephalopathy Acute Cystitis with hematuria COVID-19 History of brain aneurysms with cranioplasty/craniotomy -Patient unable to answer some questions and answers others easily - stares blankly at times when asked a question.  Husband states this is not baseline.  Not alert to month or year.  Neuro exam completely normal otherwise.  -CTH showing bilateral aneurysm clips are seen near the carotid apices, 2 on the left and a single clip on the right. There are left-sided craniotomies and a right cranioplasty is evident. Stable caliber of the ventricles and other CSF spaces with mild to moderate volume loss present. There is no mass effect. No evidence of an acute territorial infarction. No more than mild chronic small vessel white matter ischemic change.  -UA with 23 WBC, 52 RBC - having frequency in the ER with small output - denies dysuria -COVID-19 - has a mild cough (husband states is baseline with COPD), other than possible cause of encephalopathy - no other current symptoms - monitor closely.  CXR more consistent with her chronic CHF. -Started on Rocephin, follow blood and urine cultures -Monitor for COVID symptoms - no longer doing MAB inpatient.  If she develops symptoms would be a candidate for Remdesivir and steroids.  1/12 would be day 1 of symptoms.   -Pt not boosted as she had a severe reaction to Vaccine #2 which landed her in the hospital. -Supportive care with anti-tussives, VTE with Lovenox BID -Monitor on continuous pulse oximetry - wears 3 L O2 at baseline continuously.  Goal for SpO2 >88%.  Will monitor on telemetry as patient's rates shot up to 150 when up to commode.  Having small runs of Vtac on telemetry in ER. -Neuro checks Q 4 hours x 48 hours   Oxygen Dependent COPD Tobacco Abuse OSA -  not on C-pap -Wears 3 L O2 at all times -Continue home inhalers, PRN albuterol, PRN nicotine patch   Non-ischemic Cardiomyopathy Chronic combined systolic and diastolic heart failure MR Biventricular Pacemaker in situ Hypertension Prolonged QTC -Monitor on telemetry - short runs of VT noted on telemetry in ER -Monitor electrolytes and replace as necessary -Follows with doctor -CXR with signs of pulmonary edema, BNP was normal -Will change her PO Lasix to IV 40 mg once today and then resume her oral Lasix tomorrow - monitor I/O, daily weight, continue ASA, Coreg and lisinopril, Imdur   Type II Diabetes Mellitus -Humalog corrective for now, adjust as necessary   CKD III -Creatinine 1.36 - stable for patient -Dose medications for GFR 38   Hypochromic Anemia -Hgb 9.8 -Recent colonoscopy 12/21/21with hemorrhoids, polyps retrieved (1 tubular adenoma, 2nd was ulcerated Hamartomatous polyp)   Morbid Obesity -BMI 43   DNR per DPOA (husband) had paperwork at bedside - aggressive care Activity: UAT PT/OT Diet: Carb Consistent, 2 L fluid restriction, 2 G NA VTE Prevention: This patient is high risk per the VTE risk assessment tool, pharmacologic prophylaxis is indicated. lovenox has been ordered Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 75 y.o. female a past medical history of nonischemic cardiomyopathy with biventricular pacemaker/defibrillator, CKD 3, oxygen dependent COPD on 3 L O2 at all times, tobacco abuse, type II diabetes mellitus, and hypertension who presents today with altered mental status.  History is obtained from the husband at bedside as the patient is able to answer some questions but mostly stares at me blankly when questions are asked.  The patient's husband states that the patient has been in her normal state of health.  She laid down to take a nap around 1500 on 01/12.  She woke up around 1800 and was unable to answer questions properly.  She mostly would just stare at him when he would ask her questions.  He states this is completely abnormal for her.  He has not noticed any change in her appetite, nausea, vomiting or diarrhea.  She was coughing quite a bit on exam, he states this is her baseline for her chronic obstructive pulmonary disease.  He does note that a family member called him today and they have been exposed to COVID-19.  The patient is immunized with Moderna x 2, but will not be boosted secondary to a severe reaction to her 2nd dose.   Upon arrival to the ER the patient had a mild fever with a temperature of 37.4° C, hypertension with a blood pressure of 189/89.  SpO2 100% on 3 L nasal cannula, RR 25.  Labs significant for bicarb 33, creatinine 1.36, hemoglobin 9.8.  COVID-19 detected.  UA with 23 WBC, 52 RBC.  For the bedside RN in the ER, she has to use a commode frequently with very small amounts of urine out each time.  CTH showing bilateral aneurysm clips are seen near the carotid apices, 2 on the left and a single clip on the right. There are left-sided craniotomies and a right cranioplasty is evident. Stable caliber of the ventricles and other CSF spaces with mild to moderate volume loss present. There is no mass effect. No evidence of an acute territorial infarction. No more than mild chronic small vessel white matter ischemic change.  Chest x-ray with central vasculature is congested and mild interstitial pulmonary edema is suspected.  Patient was given 1 g of Rocephin.   The patient will be admitted by hospital for further evaluation and treatment Review of Systems Constitutional:  Positive for fatigue (chronic). Negative for appetite change, chills and fever.  HENT: Negative for congestion and sore throat.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough and shortness of breath. Negative for wheezing.   Cardiovascular:  Positive for orthopnea and leg swelling. Negative for chest pain.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Positive for frequency. Negative for dysuria.  Musculoskeletal:  Negative for joint pain and muscle pain.  Neurological:  Negative for dizziness, light-headedness and weakness.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Psychiatric/Behavioral:  Positive for decreased concentration.  Skin:  Negative for rash.  OBJECTIVE: BP 156/60  | Pulse 85  | Temp 99.3 °F (37.4 °C) (Oral)  | Resp 25  | Wt 122.2 kg (269 lb 6.4 oz)  | SpO2 95%  | BMI 47.72 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: She is not in acute distress.    Comments: Seen initially getting up to commode - HR up to 150 with activity (not sustained).  Increased WOB with activity.  Skin warm and dry.  HENT:     Head: Normocephalic.     Mouth/Throat:     Comments: Dry MM Eyes:     General: No visual field deficit.    Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Tachycardia present.  Pulmonary:     Comments: Tachypnea, intermittent cough.  Lungs diminished. Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.  Musculoskeletal:        General: No swelling or tenderness.     Cervical back: Normal range of motion. No rigidity.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert.     Cranial Nerves: No cranial nerve deficit, dysarthria or facial asymmetry.     Sensory: No sensory deficit.     Motor: No weakness.     Coordination: Coordination normal.     Comments: Alert to self and "hospital".  Not aware of day, month or year.  Able to answer some questions easily - others unable to find words for answers and stares.  Finger to nose and heel to shin without ataxia.  Follows commands easily.  Psychiatric:        Mood and Affect: Mood normal.   1/24/22 General Medicine progress note:  CHIEF COMPLAINT: Toxic metabolic encephalopathy   Assessment/Plan    Principal Problem:   Toxic metabolic encephalopathy Active Problems:   Dilated cardiomyopathy   Sleep apnea, unspecified type   Type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin   Essential hypertension, benign   Biventricular ICD (implantable cardioverter-defibrillator) in place   Chronic combined systolic and diastolic heart failure   Stage 3 chronic renal impairment associated with type 2 diabetes mellitus   Chronic respiratory failure with hypoxia and hypercapnia   COVID-19   Acute cystitis without hematuria   Advanced care planning/counseling discussion   DISPOSITION 1/24/2022  o Hypernatremia- resolved, check BMP again in am  o HFNC  COVID, on solumedrol, completed Remdesivir. Procalcitonin low 4 days ago o CXR noted yesterday , increased vascularity ( although weight is down and on diuretic, less likely CHF congestion )  o Off D5 W for hypernatremia, Adjust insulin  o Palliative- DNR, documentation noted o Medication compliance issue for nurses, meds shifted to IV o husband in room  Patient remains critically ill secondary to acute hypoxemic respiratory failure requiring HFNC due to COVID pneumonia requiring close monitoring and at risk for decompensation/intubation.   ADDENDUM: 1/24/2022 5:37 PM  LETHARGY - arousable nods head , short attention span  - check ammonia - Check ABG dw RT - bipap if resp acidosis / CO2 retention - check BMP spc sodium.  - perfect serve neurology sz vs Keppra lethargy ( hold IV keppra tonight ?) and re-assess. Await their response Perfect serve Pulmonary, expect answer soon  dw husband, she is DNR DNI at this time but will consider ventilatory support if needed and with chance of survival.   High FIO2 requirement for COVID PNA dw Nurse Updated colleague hospitalist 3PM shift of the circumstance MDM High, Critical care time 450 pm - 555pm  evaluating chart, labs, vitals, meds, examining and interviewing patient, discussing with bedside nurse, plans for the day, discussing diagnosis and plans, coordinating care,  concerns and counselling with patient's husband  is > 50% of the time    Toxic metabolic encephalopathy History of brain aneurysms with cranioplasty/craniotomy Episodic unresponsiveness and aphasia Concern for seizures Neurology consulted, appreciate recs CT head stable exam without evidence of an acute process EEG - possible generalized nonconvulsive status epilepticus Started Keppra Recommend outpatient neuropsych testing 1/24/2022 Keppra   Sepsis Acute Cystitis with hematuria/pyelnephritis Urine culture Enterococcus faecalis Blood cultures x4 NGTD Ampicillin1/15, last fever 1/16 Ampicillin completed When hypoxia from COVID not severe and more stable, may be prudent to re: check CT abdomen: chronic vs acute pyelonephritis. It is very assuring that she does not have bacteremia .    Acute on Chronic hypoxemic respiratory failure COPD exacerbation Tobacco Abuse OSA - not on C-pap Wears 3L O2 at baseline, currently on 6L NC - wean as able Continue home inhalers scheduled symbicort, PRN albuterol, PRN nicotine patch Continue IV SoluMedrol 40mg BID 1/24/2022 Scheduled albuterol on top of symbicort COVID management see below CPAP non compliant   COVID-19 Symptoms started 1/12, Tested positive 1/13 Vaccinated x2 - had bad reaction to second vaccine Remdesivir x5 days Started on IV SoluMedrol 40mg BID 1/17 1/24/2022 Reviewed chart + COVID test 1/13 ( week before that + family gathering then a member + COVID 1-2 days later) Asymptomatic until a day prior to admission  On baseline oxygen ( 3 liters )  until 1/18 before 1 am, started on solumedrol 1/17 and remdesivir 1/18 No paxlovid nor molnupiravir in house ( confirmed with pharmacist )  O2 requirement  7 liters up to HFNC 75% to 80% Inflammatory markers reviewed, CRP trending down , DDimer normal  Albuterol + symbicort continue solumedrol, completed remdesivir  ( LFT normal, creat checked)    Non-ischemic Cardiomyopathy Chronic combined systolic and diastolic heart failure Biventricular Pacemaker in situ Hypertension Prolonged QTC Follows with doctor CXR with signs of pulmonary edema S/P IV lasix, continue home lasix Monitor I/O, daily weight Continue ASA, Imdur 1/24/2022   lasix from 40 mg q d Check  K and creat monitoring  Resume lisinopril half usual home dose and follow BP and K and creat Resume coreg BP should be able to tolerate ( note transitioned to IV since she is not taking meds for nurses)   Type II Diabetes Mellitus Low dose corrective 1/24/2022 Hyperglycemia, add lantus 6 yesterday increased to 14 and bolus increased to very high dose on D5 W for hypernatremia and steroids for COVID She is off D5 last night, adjust insulin and follow   CKD III Renally dose meds Avoid nephrotoxins Trend BMP 1/24/2022 Baseline  1.68 from 2020 Currently 1.02  Hypernatremia 1/24/2022 Can contribute to lethargy RESOLVED  OSA history 1/24/2022 Cpap  intolerant  Normocytic Anemia Recent colonoscopy 12/21/21with hemorrhoids, polyps retrieved (1 tubular adenoma, 2nd was ulcerated Hamartomatous polyp) 1/24/2022  latest hgb 9.1,  ( oscillating from 9.8- 10.4 - 9.7 - 9.1 ) follow   Morbid Obesity Body mass index is 44.75 kg/m².   DNR per DPOA (husband) Palliative discussion  1/22  VTE Prevention: This patient is high risk per the VTE risk assessment tool, pharmacologic prophylaxis is indicated. lovenox