Age: 82.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, COVID-19 pneumonia, Carotid artery stenosis, Cerebellar infarction, Cerebral artery occlusion
Clinical narrative: Hospitalized (1.7.22 - present - still currently admitted);  COVID-19 positive (1.7.22); fully vaccinated (no booster) On admission 1.7.22 -  Brief exam:  Patient is currently intubated and sedated, ill-appearing, decreased breath sounds at the bases, abdomen soft nontender, bilateral lower extremity edema. Brief history and medical decision making: 83 y.o. male with a PMHx of CAD s/p CABG and stent (1996), HTN, CKD3b, T2DM on insulin(history of poor compliance an dover administration of insulin in the past with hypoglycemia), memory concerns, and recent elbow surgery (12/08/2021) who presented to ED with altered mental status. Per family sustained a fall during the afternoon of 1/6 and was outside for approximately 1.5 hours at which time he was found by his daughter-in-law and brought inside with a subsequent return to his baseline health. His last known well is reportedly 6 pm on 1/6. Per the patient's son, he asked a friend to check on him the afternoon of 1/7 and patient was found unresponsive in bed. EMS found him unresponsive and reportedly with blood glucose of 39. In the ED initial POC glucose was 59. He received treatment and repeat POC glucose 2 hours later was still only 56. Apparently patient has a history of prior AMS and memory issues due to hypoglycemia concerning for appropriate insulin administration.  Pt brought to ER and intubated for airway protection. Hospital course was significant for elevated troponins as well as positive COVID-19 PCR. Stroke workup including head CT was unremarkable for acute processes. Regarding acute encephalopathy; appears toxic metabolic due to current illness and hypoglycemia. D10, CT scan done and was negative for acute process. Will plan on weaning sedation this am. If encephalopathy persist will start work up with EEG , MRI , LP. NSTEMI type I v/s Type II ; in setting of underlying sepsis, COVID pneumonia and possible rhabdomyolysis component. trop 580, 1232. Will continue to trend to peak. Heparin gtt, ASA, Statin, Echo reviewed.  Acute Systolic heart failure ; no prior echo in last 10 years to compare to. echo showing mild LV dilation with severely reduced LVEF 25-30%. There appears to be akinesis of mid-distal anterior, basal-distal anteroseptal, inferoseptal and apical wall segments. . Cards following. Lastly, COVID 19 pneumonia; Multifocal groundglass opacities throughout the lungs . Start decadron. Pneumonia due to COVID-19 virus  Acute hypoxic respiratory failure  Cheyne Stokes respirations Incidentally found COVID-19 positive during admission (01/07/21) for altered mental status.  Treated for possible aspiration pneumonia with various abx. 1/7-12 (Zosyn, Cefepim, Unasyn) CXR 1/18: per my reading diffuse groundglass bilateral opacities, worse than 2 days ago    Decadron 01/08 - 01/12 but then discontinue, Solu-Medrol 60 mg q12, day # 4, will cut to 40 mg bid on 1/19  Currently on HFNC FiO2 30%, 55-- >30 l/min, titrate as necessary, STAT VBG - Duonebs every 4 hours / prn;  - Chest PT for airway clearance, frequent suctioning of secretions -I&O + 593, total 11.8 l, given Lasix 40 mg IV this am, will increase to 80 mg bid, -currently off antibiotics and afebrile, WBC increasing, was on Cefepime/Vanc 1/8-11 -check procalcitonin, MRSA PCR screen, restart Cefepime/Vanc -place Foley cath Toxic-metabolic encephalopathy  Acute ischemic stroke of right occipital lobe Chronic right caudate infarction  Rigth carotid artery stenosis  Multifactorial; hypoglycemic at time of admission - blood glucose 39; COVID positive; followed by finding of acute ischemic stroke to the right occipital lobe.  EEG 1/13-1/14 did not show seizure activity.  CTA head and neck:  Severe focal high-grade stenosis/near occlusion in the proximal right internal carotid artery.  2.  Occlusion of the right posterior cerebral artery V3 segment.  3.  Approximately less than 30% stenosis in the proximal left internal carotid artery due to atherosclerotic disease at the left carotid bifurcation.  4.  Moderate atherosclerotic calcifications in the parasellar internal carotid arteries.  5.  Patchy ill-defined opacities in the visualized upper lobes concerning for multifocal pneumonia to include viral etiologies.  MRI brain 1/11: Early subacute nonhemorrhagic moderate-sized infarction within the right occipital lobe correlating with findings on recent head CT. No findings to account for the left-sided abnormalities on the recent CT perfusion exam. Chronic infarction at the right caudate and tiny chronic right cerebellar infarct.  LP performed and negative for infectious concerns.    -will check STAT CT head to r/o bleed, new stroke  - c/w neuro checks q 4 hours; daily NIHSS - c/w Atorvastin 40 mg nightly;  - PT / OT as able ASSESSMENT / PLAN: This is a 83 y.o. who was admitted to ICU 1/7/22 for altered mental status and required intubation, incidentally found to have COVID. Was able to extubate with slightly improved mental status. CXR shows bilateral infiltrates. Over the last week, has noted waxing and waning mental status, Cheynne Stokes respirations. On 1/17/21 am noted escalation of oxygne needs from 3 liters nasal cannula to 30% high flow nasal cannula. Has been treated with steroids, diuresis, treated for possible aspiration pneumonia.   Update / Plan of Care 1.18.22: Pulmonology Consult Note:  This is a 83 year old male patient with past medical significant for CAD s/p PCI in 1996, hx of CABG, DM, HTN who was initially admitted to MICU with Altered mental status intubated on admission for airway protection. Diagnosed with COVID-19 Pneumonia on admission and found to have new acute systolic heart failure. Brain imaging showed features suggestive of stroke and he was also diagnosed with acute right popliteal DVT and was started on heparin. In regards to acute hypoxemic respiratory failure, currently his SPO2 is 97% on HFNC 30% and there is no need for intubation, I recommend continuing IV diuresis as he has been net positive since admission and he has acute systolic heart failure. Poor mental status will place him at risk of aspiration and need for re-intubation but no need for that currently.  Progress: declining Outcome Summary: No changes with high flow respiration remain elevated and C02 critical.  Neuro assessment worse this am and head CT done--evolving infarct. Cxray same as prior.  Abx started-lactic elevated. Foley for more accurate output and AKI.  Son wanting pt to still have option to have intubation so Partial Code now.  +cephalic in right arm will remove IV in that arm tonight.