Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Agitation, Anticoagulant therapy, Asthenia, Blood folate normal, Blood thyroid stimulating hormone decreased
Clinical narrative: Hospitalized (12.6.21);  COVID-19 positive (11/30/21);  Fully vaccinated Admitted 12.6.21 - Chief complaint - Pneumonia due to COVID-19 Brief history and medical decision making:  Pt is a 70 yr old F with extensive PMHx of atrial fib with Xarelto, CAD/MI, NIDDM II, GERD, HPL, Obesity, OSA on CPAP, smoker presented to ED with shortness of breath and confusion. Per son - pt became weak and fell while shopping on 11/29 - EMS was called and assessed pt; recommend going to ED but pt declined. She had worsening HA on 11/30 so son took pt ED - CT brain w/o acute pathology but pt found to have COVID-19 infection - discharged home. Had worsening lethargy, poor oral intake, weakness over the past several days - workup in the ED concerning for left thalamic infarction. Pt seen and examined at bedside - groggy but arousable. AAOx0 - denies any pain, shortness of breath, headache when asked but then falls asleep and does not answer any questions.  Plan - continue stroke powerplan, PT/OT and SLP eval. Pt currently not able to take PO intake- await improvement in her mentation and SLP eval. Holding off MRI brain until pt able to follow some commands (overnight -was agitated and received Bendadryl and then Haldol). In regards to COVID-19 PNA - not requiring supplemental O2. Complete 10 days of Decadron, as started. Will discuss with mAb team to determine if pt meets criteria for monoclonal antibodies. Acute encephalopathy -unclear etiology, pt unable to consistently follow commands to rule out focal deficits, possible stroke vs hypertensive urgency/emergency vs infection delerium -Head CT without IVC positive for new hypodensity in the left thalamus suspicious for infarction of unclear chronicity, consider brain MRI -neuro consult, await recommendations -allow for permissive hypertension -start neuro checks -PT/OT/SLP covid 19 pneumonia -covid 19 PCR positive 11/30/21 -CXR showed covid PNA -start decadron -continuous pulse ox Progress Notes from 12.14.21:  Interval History Patient is a 70 y.o. female with history of Afib, T2DM, GERD, HLD, OSA on CPAP, bariatric surgery, CAD, tobacco use, breast cancer admitted for COVID pneumonia. Psychiatry was consulted for agitation, confusion. Per chart, son applying for guardianship. Remains confused in bilateral wrist restraints. Corpak placed. B12 and folate WNL.  On interview, patient still with waxing and waning levels of alertness. Was able to respond to more questions today. Thought she was at a facility and the year was "19 something". Was able to state "I think I had a stroke". Informed her she was also treated for COVID and she states "oh yeah I think that's right". Denies any current physical complaints. Reports she has been sleeping well. Feels tired this am and acknowledges feeling confused.    Collateral: Spoke with RN who reports patient has been pleasant but confused. Did know her name and the year this AM but did not know where she was or why she was here. Trialed out of restraints but she was trying to pull at Corpak so they were resumed. Sleeping well overnight. Continues to wax and wane. Acute Encephalopathy: ongoing, likely due to acute delirium Embolic Ischemic Strokes - CT brain concerning for left thalamic stroke - MRI brain findings noted - home ASA,, Crestor, Xarelto; replace with Lovenox while refusing to take orally - Neurology consulted and followed, since signed off, plan to f/u in stroke clinic - HbA1c of 5.5, TSH of 1.84, UDS negative, UA negative for UTI - Psychiatry consult placed to assist with patient's agitation 12/13              - continuing current medications for delirium              - recommendations ongoing - Patient is at high risk for or is experiencing delirium. - During daylight hours, please keep blinds open and lights on.  - Frequently re-orient to situation, location (city, state), time (time of day, date, month/season).  - Make every effort to obtain assistive devices such as glasses, hearing aids, dentures, and other medical prostheses, as studies have shown that having these things present and available can reduce the duration of acute delirium.  - Minimize daily naps to less than three per day and less than 60 minutes if possible.  - If patient is experiencing delirium, during naps keep room lights at full brightness to maximize daytime suppression of physiological melatonin production and minimize circadian rhythm disruption.  - Consider requesting scheduled melatonin if patient has it ordered PRN. - During nighttime hours, minimize extraneous noise and interruptions as well as artificial ambient lighting.  - Minimize unnecessary vital checks and lab draws, attempting to obtain these while patient is awake if at all possible. Neuropsych assessed patient to have capacity to assign DPOA on 12/9, but not to determine a discharge plan.  Unfortunately this DPOA document has not been completed.                - 12/13 per Dr.: Upon assessment today 12/13 patient unable to name a medical DPOA hands guardianship would be pursued as discussed with social worker.              - Will await court-appointed guardianship now that patient is no longer able to assign DPOA