Age: 36.0
Sex: M
Vaccine: COVID19
Symptoms: Toxic encephalopathy, Vomiting, White blood cell count decreased
Clinical narrative: Hospitalized (12.24.21 - 1.1.2022); COVID-19 positive (12.24.21); Fully vaccinated - moderna x2 D/c Summary: BRIEF OVERVIEW:   Admission Date: 12/24/2021 Discharge Date: 01/01/2022     Active Hospital Problems   Diagnosis Date Noted POA ? RSV (respiratory syncytial virus pneumonia) 01/01/2022 Unknown ? Lab test positive for detection of COVID-19 virus 12/24/2021 Unknown   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Increased ammonia level 01/01/2022 01/01/2022 Unknown ? Hypoxia 12/25/2021 01/01/2022 Unknown ? Toxic metabolic encephalopathy 06/01/2010 01/01/2022 Unknown DISCHARGE MEDICATIONS: ? acetaminophen (TYLENOL) 500 MG tablet Take 2 tablets by mouth every 8 hours as needed for Pain. ? allopurinol (ZYLOPRIM) 300 MG tablet Take 300 mg by mouth daily. ? apixaban (ELIQUIS) 5 MG tablet Take 5 mg by mouth 2 times daily. ? atoMOXetine (STRATTERA) 40 MG capsule Take 40 mg by mouth daily. ? carvedilol (COREG) 6.25 MG tablet Take 6.25 mg by mouth 2 times daily (with meals). ? divalproex (DEPAKOTE ER) 500 MG 24 hr tablet Take 3 tablets by mouth nightly for 7 days. ? lacosamide (VIMPAT) 100 MG tablet Take 1 tablet by mouth 2 times daily for 7 days. ? levOCARNitine (CARNITOR) 330 MG tablet Take 330 mg by mouth 3 (three) times daily. At 0800, 1600, 2000 ? LORazepam (ATIVAN) 0.5 MG tablet Take 1 tablet by mouth every 8 hours as needed for Anxiety for up to 3 days. ? lovastatin (MEVACOR) 20 MG tablet Take 20 mg by mouth every evening. ? Lurasidone HCl (LATUDA) 80 MG TABS Take 80 mg by mouth every evening. Take one tablet at 1600, 2000 ? omeprazole (PRILOSEC) 20 MG delayed release capsule Take 20 mg by mouth every morning (before breakfast). At 0800 ? prazosin (MINIPRESS) 2 MG capsule Take 2 mg by mouth 2 times daily. At 0800. 2000     Active Issues Requiring Follow-up   Followup with neurology as outpatient    Followup with PCP in 5-7 days of discharge for routine hospital followup.   DISCHARGE DISPOSITION: Stable back to AFC   No future appointments.   Appointments Needing to be Scheduled   Contact information for follow-up       Next Steps: Follow up   Instructions: Followup in 5-7 days for routine hospital followup     Specialty: Neurology     Next Steps: Follow up   Instructions: Followup in 4 weeks.     Instructions for after discharge    Call the Doctor (specify)   Complete by: As directed     Call the Doctor for Persistent Nausea or Vomiting   Complete by: As directed     Call the Doctor for Redness, Tenderness, or Signs of Infection at IV or Procedure Site(s)   Complete by: As directed     Call the Doctor for Temperature Greater Than 100.3 F   Complete by: As directed     Read New Medication Instructions   Complete by: As directed     Resume Normal Activity as Tolerated   Complete by: As directed     Resume Normal Diet   Complete by: As directed         DETAILS OF HOSPITAL STAY:   PRESENTING PROBLEM: Hypoxia  Abdominal pain, unspecified abdominal location  Non-intractable vomiting with nausea, unspecified vomiting type  Pneumonia due to COVID-19 virus  COVID-19    HOSPITAL COURSE:   Patient is a 37-year-old male with past medical history of cerebral palsy, developmental delay, oppositional defiant disorder, epilepsy, recent COVID-19 diagnosis, history of stage IV testicular cancer status post chemotherapy and in remission who was admitted with nausea and vomiting and abdominal pain.  On presentation to ER he had CT abdomen/pelvis which was negative for any acute process.  He was found to be COVID-19 positive but this was felt to be residual from recent past positive test in October.  His chest x-ray on admission showed mild bibasilar atelectasis without any consolidation.  He did have hypoxia in the ER which was initially felt to be secondary to IV narcotics given.  He was admitted to Medicine.   After admission, he did increase in O2 needs and was placed on 3-4 liters nasal cannula.  He developed a fever meeting SIRS/sepsis criteria and was found to be RSV positive on film array.  Given that his COVID positive test was felt to be residual from prior positive test in October he was not treated with Remdesivir.  He was started on IV steroid for 5 day course for RSV pneumonia (finished with prednisone) and hypoxia resolved.  During his stay he developed acute encephalopathy, and he had to be placed in soft bilateral wrist restraints.  His ammonia level was found to be elevated at 146. Both Psychiatry and Neurology Service were consulted.  Psychiatry assisted with agitation while hospitalized. Ritalin was stopped. Neurology recommended decrease of home Depakote and addition of Vimpat given high ammonia level felt to be secondary to Depakote.  EEG showed background slowing without seizures. Ammonia level trended down. Patient was discharged back to his facility in stable condition.    Consultants Psychiatry Neurology   Procedures EEG     BP 102/50  | Pulse 99  | Temp 36.5 °C (Axillary)  | Resp 18  | Ht 1.727 m  | Wt 75.4 kg  | SpO2 98%  | BMI 25.27 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: He is not ill-appearing.  HENT:     Head: Normocephalic and atraumatic.     Nose: No rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: No swelling.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert. Mental status is at baseline.     H&P: CHIEF COMPLAINT: Pneumonia due to COVID-19 virus     Assessment/Plan    ASSESSMENT / PLAN:   Nausea/vomiting/abdominal pain - CT abd/pelvis negative for acute process. Shows stable liver lesions likely 2/2 prior biopsy as well as fat filled inguinal and ventral hernia.  - Hernias soft on exam. LA and WBC WNL. - Checking stool studies as well as procal and D dimer - Oxycodone PRN - Continuous pulse ox due to sedation 2/2 narcotics   COVID 19  Vaccinated. Had positive test on 10/06/21, now again positive 12/24 - Possible re infection with COVID but suspect this is residual from October - CXR shows mild bibasilar atelectasis without evidence of pneumonic consolidations - On home Eliquis, continue - Will hold on decadron or monoclonal antibodies pending further workup   Acute hypoxia - Unclear whether 2/2 COVID vs bacterial pneumonia vs PE vs narcotic induced - Workup as above - Wean O2 as able    Thrombocytopenia - Persistent since 01/2021 - Also noted to have pancytopenia in 2019 but was thought to be 2/2 chemo at that time - Checking peripheral smear   NICM, chemo induced - LVEF 30% with normal diastolic dysfunction   Chronic anemia - Hgb stable   H/o PE and renal vein thrombosis 2019 - Continue home Eliquis   Epilepsy: Depakote daily at 4pm (received dose today)     GERD: Prilosec PRN   Anxiety: Ativan 0.5mg q8 hours PRN   HLD: statin    H/o testicular cancer  - per oncology note from 2019, metastatic to lung, liver and retroperitoneal     Cerebral palsy Developmental delay Oppositional defiant disorder - Continue Rexulti, Strattera and latuda   ADHD: Ritalin bid    VTE ppx: high risk due ot COVID. Lovenox subq ordered Diet: General Code status: FULL until able to reach guardian    HISTORY OF PRESENT ILLNESS: a 37 y.o. male who presented to the ED on 12/24 with abdominal pain, nausea and vomiting. Patient is unable to contribute to history r/t drowsiness likely 2/2 recent dose of morphine along with developmental delay. Per caregiver at bedside, she is aware that he had an episode of emesis last night. This morning he seemed in normal state of health and was able to go out to lunch and participated in opening Christmas gifts. This afternoon he reported abdominal pain and had an episode of emesis, prompting presentation. His caregiver reports him having a cough today but otherwise they have not noticed any abnormalities.    In the ED, patient was tachycardic with VS otherwise stable. He did have transient hypoxia with spO2 85% which was felt to be 2/2 IV narcotics. He was reportedly weaned from oxygen though on evaluation remains on 2L. Upon patient arriving to the floor, RN reports another episode of hypoxia with patient now requiring 4L. CXR showed bibasilar atelectasis though no evidence of consolidation.  OBJECTIVE: BP 119/62  | Pulse 107  | Temp 38.1 °C (Oral)  | Resp 23  | SpO2 99%    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is well-developed. He is not toxic-appearing.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Trachea: No tracheal deviation.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. No friction rub. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Findings: No erythema.  Neurological:     Mental Status: He is alert.     Comments: Oriented only to self. Drowsy but awakens to voice.  Psychiatric:        Behavior: Behavior normal.        Thought Content: Thought content normal.