Age: 74.0
Sex: M
Vaccine: COVID19-2, FLU4, COVID19-2, FLU4
Symptoms: Mental status changes, Metabolic encephalopathy, Pneumonia, Polyuria, Prostatomegaly
Clinical narrative: Admission Date: 10/4/2022 Discharge Date: 10/11/2022  PRESENTING PROBLEM: Acute respiratory failure with hypoxia (HCC) [J96.01] Longstanding persistent atrial fibrillation (HCC) [I48.11] Acute kidney injury superimposed on chronic kidney disease (HCC) [N17.9, N18.9] Anemia, unspecified type [D64.9] Community acquired pneumonia of right lower lobe of lung [J18.9] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE:    74 year old male with memory issues, depression/anxiety, hypothyroidism, hypertension, recent SAH, and admitted with hypoxia due to Covid and CAP. He was admitted and started on ceftriaxone, azithromycin, and remdesivir. He was given one dose of dexamethasone in the ED. Spoke to patient and wife yesterday in detail. Obviously the two biggest issues are bacteremia with Enterococcus faecalis and his pancytopenia. Have been in contact with ID and appreciate update today. Also placed orthopedics consult  for swollen left knee. TTE not impressive for vegetations, but repeat blood cultures from 10/6 were positive again. So far blood cultures from 10/7 are negative.  Will likely need PICC line and long term IV antibiotics after blood cultures return negative.   10/5/2022 Blood cultures returned positive from 10/4 with G+cocci in pairs and chains. Patient was started on Vancomycin and azithromycin was stopped. Repeat blood culture that night and repeat blood cultures x 2 for am ordered.   10/6/2022 Blood cultures returned as Enterococcus faecalis and CT abdomen/pelvis performed, ID consult placed, Echocardiogram ordered, and antibiotics changed to ampicillin 2 gm Q 6 hours. Repeat cultures again placed for following am. Ortopedics consult placed.   10/7/2022 Blood cultures from 10/06/2022 returned positive. CT abdomen essentially negative. Echocardiogram revealed no vegetations.    10/8/2022 Blood cultures from 10/7 negative so far. Orthopedics found no fluid on aspiration of left knee. MRI spine negative for osteomyelitis or disciitis.   10/9/2022 Blood cultures from 10/7 remain negative. Blood cultures from 10/8 also negative, now for 24 hours. Urine from 10/5 grew back Enterococcus on 10/8 (May need to assume this was the source vs prostatitis)   10/10/2022 Blood cultures from 10/7 remain negative. Blood cultures from 10/8 also remain negative.    10/11: Blood cx on 10/8 with GPC in pairs and chains. ID added ceftriaxone for synergy. Patient transfer to hospital for TEE. Discussed with hospitalist team.    Admission Date: 10/11/2022 Discharge Date: Oct 16, 2022  PRESENTING PROBLEM: Bacteremia [R78.81]   HOSPITAL COURSE: Patient is a 74-year-old male with a past medical history of early-onset Alzheimer's disease, atrial fibrillation, CHF, OSA with CPAP, hypertension, hypothyroidism and obesity who presented secondary to a chief complaint of Enterococcus bacteremia.  He was admitted to inpatient on 10/04/2022 for hypoxia due to COVID-19 pneumonia.  He was treated with a Zithromax and Rocephin initially due to concern for community-acquired pneumonia.  He received a course of remdesivir due to the timing of his symptoms.  His blood culture grew Enterococcus.  Infectious Disease was consulted.  He continued to have persistent Enterococcus in his blood cultures.  He was transition to Rocephin and ampicillin per ID.  Due to history of knee arthroplasty 4 years ago he had an attempted aspiration of his left knee.  This was negative for infection.  TTE showed no obvious vegetation.  His respiratory status improved, but with the persistent blood cultures he was transferred for a TEE to Hospital.   TEE was negative for vegetation.  Infectious Disease recommended an ultrasound of his left knee which showed a loculated effusion.  Knee x-rays were recommended and showed stable effusion.  Orthopedic surgery was consulted and attempted aspiration of the knee joint, but it was a dry tap.  They recommended to be performed under fluoroscopy by Radiology.  Culture showed NGTD at time of discharge 10/16; follow up with ID clinic for final result.  Orthopedic surgery team reviewed cell count results stated this is likely chronic PJI and that patient should follow up with his Orthopedic surgeon   PT/OT recommended home with home care.  His PICC line was placed on 10/15.  He was discharged home on PCN G 10/16/22 with ID, Orthopedic surgery and PCP follow up.     Patient's home Eliquis was resumed 10/16. He had one episode of maroon colored sputum; patient will monitor closely for recurrence and seek appropriate medical attention if persistent.   Home hydralazine 100 mg TID continued to be held at discharge. Patient to follow up with PCP in office to see effect of resuming home lasix on BP and receive further instruction from PCP about resuming this medication