Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: Urinary tract infection, Urine analysis abnormal, Vitamin D, Walking aid user
Clinical narrative: PROVIDER PROGRESS NOTE 2/8/2022 ASSESSMENT: This is a 85 y.o. female with PMH of Parkinson's disease with unspecified speech disturbance, lack of coordination, and cognitive dysfunction, hypothyroidism, who was diagnosed with COVID on 1/20/22, presented on 2/2/22 with weakness, fatigue, and decreased appetite.     PLAN Genearlized weakness Severe fatigue Multifactorial in setting of COVID (positive 1/20), UTI, hypercalcemia, poor PO intake and what is though to be Parkinson's disease (dx'd about 6 months ago). Lives with her husband who is worried he cannot provide support she needs and that she will have a fall at home, has had falls PTA. These were witnessed and with husband's help pt was able to get off ground with no acute injuries. - PT/OT - mgmt of comorbidities as below -TCU at discharge   Acute cystitis - resolved UA c/w UTI in setting of leukocytosis. At admit met sepsis criteria with leukocytosis 20k, acute encephalopathy related to infection. Received rocephin in ED. However UCx returned with mixed flora. Given clinical picture with leukocytosis and confusion, favored cont tx of UTI, so rocephin was continued.  Thought that UCx could be poor sample and not indicative of non-infection. Reviewed CXR from admit and difficult to discern if opacities from COVID only vs possible superimposed bacterial PNA. Procal checked for further w/u and elevated >3. Started tx for bacterial PNA coverage (see more below). - completed course of IV rocephin for UTI - add'l abx as below for PNA   Acute respiratory failure with hypoxia, Improved Bacterial PNA, unspecified organism, CAP No hypoxia noted at admit. CXR with bilateral pulmonary opacities. Initially findings thought to be solely from recent COVID infxn (convalescent). Started on rocephin at admit d/t UTI concerns, since completed. 2/4 noted to have new hypoxia with O2 sats 85% on room air. Has been intermittently on RA and O2 via NC. Procal 3.58->0.38. Poss aspiration component, added anaerobe coverage 2/6. Was on 1L overnight, RA this AM.  - cont IV azithromycin for PNA (Day 5 today, complete today) - cont IV unasyn for anaerobe coverage (2/6-2/11), transition to Augmentin at discharge - completed rocephin for UTI -monitor O2     Recent COVID-19 in convalescent phase Sxs of fatigue for roughly 2 weeks PTA. Had productive cough but now resolved.  COVID positive on 1/20/22. O2 sats are stable on room air on admit. CXR with pulmonary opacities likely from prior COVID.  No indication for decadron or tocilizumab as pt in convalescent phase. - could consider steroid if respiratory status does not improve w/ abx regimen above however pt is convalescent and has other causes for hypoxia - on IVFs for hypercalcemia and poor PO intake, since resolved - monitor - standard dose lovenox as pt in convalescent phase   Hypercalcemia, Resolved Primary hyperparathyroidism Calcium 12.3 at admit. Likely multifactorial due to poor PO intake with dehydration over past week or so, possible excess vitamin A (Vit A supps PTA), dehydration, immobility d/t weakness and hyperparathyroidism. Appears up to date on most cancer screenings for woman of 85 y.o. 2/7: iCa normalized to 1.28->1.13. PTH elevated. 2/4: given 1x dose zoledronic acid - discussed w/ pharmacy. Vit d level wnl (not the etiology for elevated PTH) - D/c IVFs at 75cc/hr w/ NS - check iCa daily - hold PTA coenzyme Q10, Vit D and Vit A supps - at DC will likely need bisphosphonate - endocrinology f/u   Parkinson's disease Follows with Doctor through clinic of Neurology. Seen 1/4/22 in clinic. Per neuro notes she has some baseline speech disturbance (unspecified type), lack of coordination, and some cognitive dysfunction related to her Parkinson's disease. At her visit 1/4 neuro increased her carbidopa/levodopa to 2 tables 4 times a day. She has been working w/ SLP, OT and PT.   2/6/2022: Per family request, a psychiatrist who has experience with delirium, Parkinson's diseaes, dementia's, etc., provides some insights.  He reports roughly 6 months ago she was ambulating independently with just a cane.  However has had drastic changes in her mobility. She was diagnosed with Parkinson's disease and has been following with clinic of Neurology where they have been titrating sinemet.  Doctor reports the sinemet has led to no improvements and thinks it may be making some aspects worse as it is titrated higher.  He states her symptoms seems more atypical parkinson's to him. She has no resting tremor. He states her biggest issue at time of dx was trouble initiating movements. Such as if she was standing and instructed to walk "it was like her foot was nailed to the ground".  He has some suspicion for Lewy Body Dementia.  He also notes cognitive decline over the past several months where she has been more forgetful. 6 months ago he states she was A&O x3. CT head w/o acute findings. Noted global parenchymal loss, microvascular disease.   Today: Pt's husband brought list of requests from a neurologist, vascular dementia work up, MRI, sinemet dose adjustments. Discussed with pt and husband that these items should be done on an outpatient basis with pt's neurologist in clinic.    - cont PTA sinemet - Outpatient Neurology follow up for further dementia work up, sinemet dose adjustment, MRI     Acute on chronic encephalopathy, metabolic, Improved/Resolved Per husband report, has mild baseline cognitive deficits in setting of Parkinson's disease. I spoke to doctor as above, and 6 months ago was A&Ox3, aware of time/date and surroundings. This has progressively worsened over the past 6 months.     Multifactorial in setting of primary hyperparathyroidism w/ hypercalcemia, UTI, COVID, bacterial PNA. Dx of parkinson's in past 6 months as above.     Some improvements noted w/ tx of UTI, calcium however remained confused. Today is A&Ox3. - mgmt as above - melatonin qhs - precuations: maintain sleep-wake cycles, minimize night time interruptions   Dysphagia w/u Mild Swallowing Impairment SLP consulted - recommend video swallow. Per SLP diet okay for regular food and thin liquids. Video swallow w/out evidence of aspiration.  -SLP following -Diet per SLP: Level 7 Reg, no straws, alert and upright for meals     Hypothyroidism - cont PTA levothyroxine