Age: 49.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anticoagulant therapy, Aspiration, Axillary vein thrombosis, Bipolar disorder
Clinical narrative: COVID+ 11/23/2022.  Vaccination status - moderna x4 BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider at Discharge: None Physician, DO None Admission Date: 11/23/2022 Discharge Date: 11/30/2022   Active Hospital Problems   Diagnosis Date Noted POA ? Acute and chronic respiratory failure (acute-on-chronic)  11/23/2022 Unknown ? Stenotrophomonas and E. coli Pneumonia 11/23/2022 Yes ? Obesity hypoventilation syndrome 11/23/2022 Yes ? Acute/Subacute Left Parietal Infarct 11/23/2022 Yes ? Seizure disorder 11/23/2022 Yes ? Bipolar affective disorder 11/23/2022 Yes ? Acute possibly toxic, metabolic, or infectious encephalopathy 11/23/2022 Yes  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute and chronic respiratory failure (acute-on-chronic) [J96.20]   HOSPITAL COURSE: Patient is a 50 year old male resident with medical history of oxygen dependent COPD, chronic hypoxemic and hypercapnic respiratory failure, OHS, OSA non-compliant with Bipap, bipolar disorder, schizoaffective disorder, seizure disorder, GERD, tricuspid regurg initially presented to hospital 9/17/22 for respiratory distress. His course was complicated by E.coli pneumonia (treated with ceftriaxone 7 day course), aspiration event resulting in acute respiratory distress requiring intubation and mechanical ventilation on 9/19, MRSA pneumonia (linezolid x10 days) and seizures. He had similar prior hospitalizations for pneumonia and COPD exacerbations requiring trach placement. Tracheostomy was placed 10/3. Discharged to Select LTACH 10/12/22 for continued ventilator weaning. He was weaning from vent on t-piece - tolerating well and was advanced to and oral diet. Approximately 11/13 he started to decline with decrease in LOS, shock requiring vasopressors and back on the ventilator. He had been febrile and encephalopathic during this time. 11/15 he was noted to have grand mal seizure by staff and was given 8mg Ativan. EEG placed but did not reveal seizure activity.    11/22 he became unresponsive. MRI brain 11/22 with acute to early subacute left parietal infarction, chronic right frontal infarction, chronic ischemic demyelination, acute on chronic paranasal sinusitis, lesion within the left ethmoid sinus (could be mucocele), marked abnormal tissue in the left mastoid sinus. Sputum culture from 11/20 grew E.coli and Stenotrophomonas. 11/23 he is arousable to voice but remained encephalopathic, so decision was made to admit to ICU. Given concern for meningitis he was started on ampicillin, vancomycin, cefepime, and acyclovir, as well as Bactrim for the E.coli/Stenotrophomonas PNA with ID following closely. ENT consulted for ethmoid sinus lesion and felt this was a mucocele and could be followed up in 1-2 months. Neurology following for stroke and meningitis. Psychiatry also consulted for polypharmacy in setting of bipolar/schizoaffective and recommending keeping clozapine as is for now. Tested positive for COVID on 11/23, started on Decadron. Concern for seizure activity early 11/24, requiring propofol gtt and norepinephrine, but no seizure noted on EEG. RUE subclavian, axillary, brachial vein DVT 11/25, started heparin gtt. LP 11/25 with protein 165, glu 91, 1 WBC, 220 RBC. MRI of brain 11/25 was negative for acute ischemia and showed no convincing evidence suggestive of meningitis. Course complicated by hyperkalemia - possibly related to heparin and treated with Lokelma. Improving responsiveness, alert and following simple commands as of 11/26.  Hemodynamically stable, awaiting discharge to LTAC  D/C to Hospital LTAC 11/30/22