Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: Anaemia, Anticoagulant therapy, Bacteraemia, COVID-19, Central venous catheterisation
Clinical narrative: Date of Admission:  8/29/2023   Date of Discharge: 9/11/2023    Problem List and Treatment Plan: 1. COVID-19 Disease No treatment Isolation precautions for 20 days after positive test (8/29) per Facility protocols. Ends on 9/19   2. Staph Hominis Bacteremia SEPSIS Cefazolin dosed after dialysis. 2 mg IV on 9/12 will complete treatment.    3. Unspecified movements Unclear etiology.  - keppra 500mg PO BID - Supplemental keppra 500 PO TThS after dialysis   4. CAD with stent History of PE -  Atorvastatin  - ASA - Stopped apixaban due to black stools   5. ESRD HD TThS   6. GI PPx  - pantoprazole 40 mg  Pending Study Results at Discharge:   7. Anticoagulation: Patient and family did not want GI bleed work up. Follow up CBC 9/12 With shared decision making, patient and family desire to continue apixaban treatment. Advised they can revisit their decision at any time.   Final Diagnoses:  Active Hospital Problems   Diagnosis   ? LONG TERM NON WARFARIN ORAL ANTICOAGULANT THERAPY       Apixaban (Eliquis) 5mg BID Indications:  Acute DVT/PE first episode ? provoked   Expected length of therapy: Indefinite (Provider to assess risk vs benefits periodically)  Considerations: Dialysis patient   HC pool: PHARMACY SERVICE       Periop Guideline Reference:   Go to Clinical Library ==>  Search: Anticoagulation Management - Perioperative- Anticoagulation Services Guideline     ? ESRD ON HEMODIALYSIS       ESRD: On hemodialysis TTS. Dialysis access:  Left IJ permcath Failed AVF/AVG in the past.   ? PRESENCE OF STENT, LEFT CORONARY ARTERY, ANTERIOR DESCENDING BRANCH       PCI 7/23/2015:Left main severe distal - bifurcation stenosis, LAD severe in-stent restenosis and calcification, LCx severe eccentric ostial stenosis and calcification. LAD 80% in-stent restenosis treated with cutting balloon, antioplasty, deployment Resolute 3.5x22 mm drug eluting stent. Excellent stent-to-vessel apposition by IVUS. PCI 8/16/2011 - 4x15mm Integrity bare metal stent placed at ostium of left anterior descending artery and post-dilated to 4.2mm. Stent well apposed by intravascular ultrasound.    ? ANEMIA OF CHRONIC DISEASE   ? FOCAL MOTOR SEIZURE   ? SEIZURE, UNSPECIFIED   ? WEAKNESS OF BILAT LEGS   ? COVID-19 DISEASE   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)   ? CAD WO ANGINA, PRESENCE OF STENT       Resolute Integrity stents left main bifurcation in to LAD and LCx, CCL SFK 7-23-2015   ? HX OF NON ST ELEVATION MI   ? HTN (HYPERTENSION)   ? SPINAL STENOSIS OF CERVICAL SPINE     Resolved Hospital Problems   Diagnosis Date Resolved ? (Principal) SEPTIC SHOCK 09/09/2023 ? GRAM POS BACTEREMIA 09/09/2023     Discharge Disposition:  Skilled Nursing Facility   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course with Narrative: 85-year-old male presented to ED with slurred speech and facial asymmetry.  Initially treated as a stroke rule out, with negative head CT.  Patient given overnight dialysis and put back in the ED.  In the morning, patient became unresponsive and was transferred to ICU.  Patient patient was COVID-positive in 2 out of 2 initial blood cultures grew staph hominis.  In ICU, patient began having generalized seizure-like movements.  Patient was started on Keppra for seizures.  Was given course of remdesivir and Decadron for COVID.  Antibiotics were narrowed from initial vanco, doxy, and zosyn to cefazolin with the return of speciation and sensitivities. Cerebell and EEG showed potential diffuse encephalopathy but no definitive seizures. Patient became responsive and was transferred out of ICU. MRI unclear of hypoxic injury vs post ictal state to cingulate gyrus. Unintentional movements resolved with keppra. Covid improved with no oxygen demand on 9/4. Patient had negative blood cultures from after first dose of antibiotics. IJ permacath replaced as potential source of infection. Left brachial AV graft was advised for removal, but patient and family declined removal. While admitted, patient had intermittent dark colored stools. Patient and family did not want evaluation over potential GI bleed. Discussed anticoagulation with family. Risks, benefits, and alternatives to continue Apixaban discussed. Patient and family decided to continue apixaban. Patient was medically stable and able to have dialysis in chair. Cleared for discharge to SNF for physical therapy.       SNF Care: 1. Reason for SNF placement: Daily physical therapy 2. Expected SNF goals: Improved functional status 3. Anticipated location of disposition: Home 4. Condition prior to discharge: No longer needs daily therapy 5. Home/Social Situation: Lives at home and has caretaker help with ADLs   Primary Procedures:  Procedure(s): CENTRAL LINE EXCHANGE   Secondary Procedures: None   Complications: none   Consults: Vascular surgery,    Smoker: No.   Code Status at Time of Discharge: DNR     Subjective 9/11/2023: Mr. reports doing well. Denies shortness of breath or pain. He is feeling ready for discharge and is unhappy with all the lab draws while inpatient.   Physical Exam 9/11/2023 : BP 146/49  | Pulse 75  | Temp 97.8 °F (36.6 °C)  | Resp 18  | Ht 5' 5.98"  | Wt 60 kg (132 lb 4.4 oz)  | SpO2 97%  | BMI 21.36 kg/m²     General appearance - Alert, no acute distress Mental Status - alert, oriented x 3, slurred, but coherent speech. Improved since yesterday. Chest - CTAB. Heart - regular rate and rhythm Abdomen - soft, nontender, nondistended, no masses or organomegaly Extremities - No lower extremity edema. RUE contracture at wrist. LUE non pitting edema with no overlying edema or pain. Neuro - No re-demonstration of myoclonic movements.  Vascular - Graft left proximal brachial region as pictured bellow          Note Details  Author (M.D.) File Time 9/11/2023  2:13 PM Author Type PHYSICIAN, RESIDENT Status Cosign Needed Last Editor (M.D.) Specialty GENERAL, OTHER Hospital Acct # Admit Date 8/29/2023  ED to Hosp-Admission (Discharged) on 8/29/2023  ED to Hosp-Admission (Discharged) on 8/29/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders Procedures   Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  CENTRAL LINE EXCHANGE From 9/6/2023 to 9/11/2023  Hospital Problem List   HX OF NON ST ELEVATION MI  HTN (HYPERTENSION)  CAD WO ANGINA, PRESENCE OF STENT  GERD (GASTROESOPHAGEAL REFLUX DISEASE)  SEIZURE, UNSPECIFIED  FOCAL MOTOR SEIZURE  SEPTIC SHOCK Resolved  SPINAL STENOSIS OF CERVICAL SPINE  WEAKNESS OF BILAT LEGS  COVID-19 DISEASE  GRAM POS BACTEREMIA Resolved  LONG TERM NON WARFARIN ORAL ANTICOAGULANT THERAPY  ESRD ON HEMODIALYSIS  PRESENCE OF STENT, LEFT CORONARY ARTERY, ANTERIOR DESCENDING BRANCH  ANEMIA OF CHRONIC DISEASE Care Timeline  08/30   Admitted to ICT-INTENSIVE CARE NURSE UNIT from ED 1216 08/31   Transferred out of ICT-INTENSIVE CARE NURSE UNIT 2141    Rapid Response 09/06   CENTRAL LINE EXCHANGE 09/11   Discharged 1728  Discharge   SNF - Skilled bed (or Subacute)   SNF Orders (Printed 9/11/2023)   Follow-Ups: Follow up with CENTER-SNF   Discharge Orders CBC + DIFF (AT REG LAB).