Age: 37.0
Sex: F
Vaccine: COVID19
Symptoms: Drug screen positive, Drug withdrawal syndrome, Encephalopathy, Exposure during pregnancy, Gestational hypertension
Clinical narrative: Patient is a 39 y.o. female with past medical history of multiple sclerosis, mood disorder and substance use disorder who presented at 37w5d with a chief complaint of nausea/vomiting . Decision was made to proceed with RLTCS 2/2 medical comorbidiites including positive fentanyl and COVID per OB team. POD#3, concern for acute altered mental status including disorientation to time, denial of recent delivery and unaware of why she was hospitalized, without any hallucinations. Patient was subsequently admitted to hospital on 8/1/2023 for continued management. In the hospital, CT head showed multifocal low-density lesion in B/L cerebral hemispheres. MRI COW/carotid showed multifocal confluent, pat MRI COW/carotid showed multifocal confluent, patchy regions compatible with PRES. Patient's encephalopathy improved daily. Patient was evaluated by neurology who signed off with recommendations of repeating MRI in 2-3 months to ensure resolution of PRES. Behavioral health consulted and recommended outpatient patient.  Patient's remaining chronic conditions were also managed as outlined below, and the remainder of patient's stay was unremarkable.  Patient was discharged on 8/7/2023 in good condition.  Patient was given return precautions and instructed to follow up with PCP, counseling, and SUD treatment.  Acute metabolic encephalopathy POA Presented w 7/31confusion, impaired memory, and delusional thought content 8/1 Pt nonverbal and uncooperative for exam Per chart review, concern for multifactorial delirium per behavioral health Ddx includes PRES, multiple cortical infarcts, delirium due to multiple etiologies, encephalopathy, brief psychotic episode with postpartum onset, opioid withdrawal, or possible reaction to recent IV steroid treatment (ended 7/31) RPR non-reactive on admission 7/27 Vitamin B12, thiamine, calcium, ammonia, TSH WNL 08/01 CT head: Multifocal low-density lesion in b/l cerebral hemispheres. 08/02 MRI COW/carotid: multifocal confluent, patchy regions od subcortical/cortical hyperintense T2/FLAIR abnormalities involving b/l cerebral hemispheres compatible with PRES.   Discussed concerns w BH, felt it still may be due to encephalopathy Plan to keep overnight until seen by team and repeat evaluation by BH Will need repeat MRI brain 2-3 mo after DC. Needs to re-establish with neuro, previously seen by Dr.    COVID Originally presented w nausea, vomiting, cough 07/27 COVID +  07/27 CXR: Prominent interstitial markings in L mid-lower lung. Possible underlying bronchitis or developing PNA.  Completed isolation 8/7/23   Right Upper Extremity Abscess 07/30 CT RUE: probable small soft tissue ulcer anterior antecubital fossa with small rim enhancing abscess adjacent to a vein in this region History of skin abscesses +MRSA  Injects fentanyl, admission UDS +fentanyl BC x2 NGTD, ID consulted Started on vancomycin on 7/27, switched to linezolid Completed Linezolid 600mg BID for total of 5d   Substance Use Disorder Current IV fentanyl use. Last 1 week ago.  07/27 UDS+ Fentanyl Counseling (8/9/23) @ 1715. Appt for SUD treatment (8/10/23) @ 0900   S/p repeat low transverse cesarean section  Gestational hypertension Met criteria for gHTN during admission Started on procardia xl 30 mg bid, which was reduced to daily This am, SBP 111, will stop procardia and monitor Acute blood loss anemia, resolved QBL 550 mL from C-section Hgb 8.0>14.5>11.4 Continue daily iron supplementation.   Hepatitis C virus infection ALT 8/AST 18 Will need to be off of substances x6 months before being able to start hepatitis C treatment per ID   Multiple sclerosis exacerbation Previously on biologic but has not been treated recently. Physicians office lost contact with patient.  S/p IV methylprednisolone 1000mg x3 days (7/29-31). Dose from prior delivery