Age: 90.0
Sex: M
Vaccine: COVID19
Symptoms: Dehydration, Delirium, Dysphagia, Encephalopathy, Enteral nutrition
Clinical narrative: Patient was initially presented on 12/12/2021 with a chief complaint of sore throat, cough, and congestion. Patient was recommended to use cough syrup and consider testing following day for COVID-19 since the symptoms just started. Steroid prescription was provided as well. According to the daughter the SpO2 was 88% at home and he is not on any supplemental oxygen. Subsequently, patient developed change in mental status and difficulty swallowing on 1 pm and therefore he was brought to emergency room via EMS around 2:00 p.m.. Upon evaluation in the ED BP was 168/75 with a heart rate of 76, patient was afebrile SpO2 94% in 2 L of oxygen. Patient noted to have left-sided facial droop and drift of the left upper extremity per ED physician. Code stroke was activated. CT of the head without contrast did not show any evidence for acute stroke patient was given 300 mg aspirin rectally. ED physician determined that patient is not a candidate for tPA because of the symptoms were non disabling and are improving. CTA of head and neck reported localized high-grade stenosis of the distal left vertebral artery at the vertebrobasilar junction. No evidence of thrombotic occlusion of the arteries of the head. X-ray of the chest reported to have patchy bilateral infiltrates and evidence of pacemaker and sternotomy wires. SpO2 dropped to 89% in room air and was placed on oxygen. Patient was subsequently admitted for further evaluation and treatment under Hospital Medicine with neurology service on consult. Patient was evaluated by Dr. and ordered an MRI as well as echocardiogram to evaluate for PFO or thrombus. Hemoglobin A1c is 6.9 and she was in agreement with aspirin 81 mg and atorvastatin 40 mg daily. She also recommended to continue with risk factor modification. Patient started improve with COVID-19 pneumonia and required only minimal oxygen. Oxygen evaluation showed he needed oxygen on ambulation. Patient was discharged to home however it was canceled as he was unable to get into the car on 12/14. Patient was brought back to have the MMR arranged however he noted to have a seizure episode with eyes rolled up. Updated this event to neurology service Dr. and she recommended to order EEG and reported to have moderate to severe diffuse encephalopathy changes is can be seen in metabolic encephalopathies but also can present in ictal or postictal state. RN texted Dr. in regard to the etiology of the seizure episode. Apparently she responded that systemic infection, metabolic derangement and advanced age as well as cortical atrophy predisposing factors to trigger seizure or seizure-like movements. Patient also spoke during the event and therefore it does not appear to be a true seizure event. Although MRI is unable to be done patient has had several consecutive CT of the head scan and none of them showed finding suspicious for a mass or strokes. Initially on admission IV fluid was discontinued due to the COVID-19 pneumonia and patient was able to maintain oral hydration. However, patient was made NPO concerning for aspiration and therefore he was started on D5 at 50cc/hr. to maintain hydration. Patient continued to have significant delirium and unable to provide any oral medications. Therefore, some of the medications were changed IV. Patient also started to have fever and blood cultures, CRP and procalcitonin were ordered. Patient have evidence of bacterial infection likely due to aspiration pneumonia. He was started on IV Unasyn and the MRSA PCR was ordered. Patient was also attempted for tube feed via NG tube due to lack of nutrition. However it was unsuccessful. Patient also developed acute kidney injury due to prerenal azotemia and sepsis. Daughter was updated of all the attempts. Daughter came to the hospital after discussing the plan of care with the her sibling as well as the mother. She requested to place the patient under comfort measures. The order was placed and also medications for comfort measures were ordered on 12/18. Patient expired on the same-day and pronounced at 2315 per local Healthcare policy.