Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: C-reactive protein increased, COVID-19, Carbon dioxide normal, Chest X-ray abnormal, Confusional state
Clinical narrative: 82 y/o female with history of dementia and Parkinson's (AOx1-3 at baseline), osteoporosis, HLD, GERD, rectal cancer s/p resection x2 (in 2010), recent hospitalization 10/23-27 for left hip fracture s/p surgical nailing 10/24/2021, who presented 11/5 with worsening weakness and drowsiness.  She has been vaccinated x3, symptom onset approximately 11/2, tested COVID(+) on 11/4 and again 11/5 on admission to hospital.  Admitted for COVID-19 disease.    She was placed on 2L NC and received Decadron 6mg x4 (11/5-11/8).  Did not receive Remdesivir due to family preference and due to the fact that her oxygen needs were minimal (though family amenable to Remdesivir if her o2 needs were to increase).  Decadron was then discontinued when patient developed worsening confusion and agitation on 11/8, and given that her oxygen requirements were stable/improving.   Her agitation has since resolved, though she has remained AOx1 throughout hospitalization which is consistent with her baseline.  On 11/8, she was deescalated to room air, however today 11/9 she required 2-3L NC.  Additional workup revealed stable CXR with no new changes, she remains afebrile/HDS with no leukocytosis, and her 2-3L NC requirements were similar to her prior requirements when she was discharged to SNF in 10/2021.   Likely has a component of atelectasis as seen on CXR. Today, she is satting well on 1.5L NC.   Patient is hemodynamically stable.  Will be discharged to healthcare center today, where she will continue to work with physical therapy.     Plan by problem list # COVID-19 infection # AHRF Found COVID(+) on 11/4.  Vaccinated x3 (booster 11/3/2021).  Symptom onset 11/2 with weakness, confusion, lethargy, and SOB, productive cough with light yellowish sputum.  Unlikely PE (negative CTA) or superimposed bacterial infection (no +imaging findings, WBC normal, remains afebrile).   MRSA negative. Was on Vancomycin 11/6-7 for BCx GPC in clusters (1 out of 2), later discontinued when BCx resulted with staph hominis (likely contaminant).  S/p Decadron 6mg (11/5-8) which was discontinued in setting of agitation. Remdesivir deferred per son's preference and pt only requiring minimal O2. Productive cough has improved.  Initially on 2L NC, then transitioned to RA on 11/7. Required 3L NC starting on 11/9.  Repeat CXR on 11/9 shows no new changes. Likely 2/2 atelectasis (pt had previously been discharged on 2-3L NC during her prior hospitalization). Concern for PE given recent hip surgery and limited mobility, however pt is HDS.   Now satting well on 1.5L NC. - Per discussion with son/DPOA Kris: DNR/DNI, ok for steroids/antibiotics/pressors - CTM respiratory status; readmit to hospital for Remdesivir and Decadron if o2 needs worsen              Son is amenable to Remdesivir if oxygen requirements increase; please discuss with him first.             LFT's and Cr/GFR normal.   - Lovenox 40mg daily - Benzonate prn cough - Trend inflammatory markers (D-dimer, CRP) qod - Dispo: Will require 20d total isolation for COVID.   Lives at home with partner and partial home caregiver; family is currently in the process of arranging for 24/7 caregiver.    # Agitation, AMS # Parkinson's/dementia On presentation pt was AOx1 (compared to AOx3 earlier in the day at subacute per chart review) and since admission has remained AOx1.  Per son, current mental status is consistent wiith patient's baseline, where she varies between complete lucidity and confused (sometimes with hallucinations, in setting of Carbidopa-levodopa use). At baseline, pt has dementia and Parkinson's, on PTA Carbidopa-Levodopa.  Thus less likely acute encephalopathy; however, if acute, differentials include respiratory infection (as described above); less likely abdominal (normal LFTs), urinary (UCx mixed flora), skin (no abscess on exam); as well as less likely etiologies such as electrolyte imbalance (chem10 wnl), hypoxia/hypercarbia (satting well on RA).  AMS initially stable/improving, however 11/7 overnight became increasingly agitated, thus decadron discontinued.  Improved 11/8 overnight without any agitation or need for psychotropic medications. - Melatonin 3mg qhs - PTA Carbidopa-Levodopa 5x/d (36.25-145mg + 23.75-95mg) - PTA Fluoxetine 20mg      # Deconditioning # L intertrochanteric fracture, s/p surgical nailing Sustained L intertrochanteric fracture and cervical vertebral fracture 2/2 mechanical fall 10/23, s/p surgical nailing 10/24.  Was discharged to center for post-op recovery, and there she had been on Day #5 (out of 10-14) of PT when she presented here for current admission.  At the time, she had been able to stand up and ambulate short distances with walker/assistance.  Currently denies any hip pain. - ASA dose reduced as below - continue to work with PT at center - Continue c collar for 3 months from initial injury  # Low PO intake # Oliguria, resolved