Age: 72.0
Sex: M
Vaccine: COVID19-2
Symptoms: Confusional state, Culture urine positive, Deep vein thrombosis, Delirium, Diabetes mellitus management
Clinical narrative: Patient is a 72 y.o. male admitted to the hospital on 12/11/2022 with reports of worsening confusion, and reported episode of emesis that appeared coffee ground in nature.  He had recently been diagnosed with COVID, and was also found to have mild AKI and a possible UTI.   Discharge Diagnosis and Associated Hospital Course   Acute Metabolic/Toxic Encephalopathy Delirium Multifactorial, in the setting of AKI, COVID, and possible UTI.  Intermittent confusion also noted over the past hospitalizations.  May have some underlying cognitive impairment.  Vitals stable, patient pleasantly confused (oriented to person/place) at discharge.  Treating underlying infectious/metabolic processes.  Stable to return on 12/13/22.   Abnormal urinalysis With abnormal UA and encephalopathy.  Unclear if indicative of active infection vs colonization, in setting of chronic Foley.  Had been on Keflex and Methenamine for suppressive therapy for infections. Recent catheter exchange 12/7 with Urology.  Urine culture growing >100 K proteus.  Blood cultures negative.  Patient received cefepime during admission.  Culture reviewed, plan to discharge on Omnicef to complete 7 day total course.  Resume prophylactic antibiotics once Omnicef completed.   COVID-19 - Presented with: encephalopathy - Symptom onset: 12/10 - Positive COVID-19: 12/10  (reportedly positive 12/9 at facility) - Vaccination status: Vaccinated - CXR on admission showed no acute cardiopulmonary process - Oxygen status: Room Air  - On Paxlovid per ID.  Complete course as prescribed.   - DVT prophylaxis: Resume Eliquis at dose of 2.5 mg BID at discharge.   Coffee Ground Emesis Reported prior to admission.  Patient unable to provide confirmatory history. Hemoglobin stable since arrival,  no witnessed emesis or melena since arrival. Plan for 6 week course of PPI total.  No GI consult pursued.  Ok to resume anticoagulation at discharge.  History of pulmonary embolism and proximal right lower extremity DVT  Admitted to GMC 6/1 - 6/3/22 with submassive PE s/p successful catheter-directed thrombectomy on 6/2/22. Also found to have an acute proximal DVT of the right lower extremity at that time.  Suspected to be provoked by recent long-distance car trip at that time.   Repeat right lower extremity venous doppler on 10/17/22 with chronic DVT in the right popliteal and gastrocnemius veins, demonstrating partial resolution of previous thrombus.  Cardiologist in October (Dr.)  had recommended 2 additional months of anticoagulation at that time.  At this time, patient has completed 6 months of therapeutic anticoagulation.  In setting of COVID illness and current debility, recommend transition to Eliquis 2.5 mg BID as prophylactic dose until functional status improves.  Follow-up with Dr. as directed.   AKI on CKD III Likely in the setting of decreased PO intake, GI losses, and concomitant ACE-I therapy.  Creatinine baseline 1.1-1.2, up to 1.46 on admission.  Has improved with IV fluids to 1.03 at discharge.  OK to resume ACE-I at discharge.   Normocytic Anemia  Noted on previous admission in the setting of hematuria.  Hgb on discharge was 9.2.  Hemoglobin currently stable at 10.1 at time of discharge, no witnessed evidence of GI bleeding.  Follow-up lab work as outpatient at the discretion of outpatient providers.   Insulin Dependent Diabetes Mellitus Type 2 Per history.  Home regimen includes basal/bolus insulin (50 units Lantus and SSI) as well as Glimepiride.  Current glycemic control adequate, had been on liquid diet during hospital stay. In setting of acute illness, will decrease Lantus from 50 to 40 units daily at discharge, sliding scale insulin coverage alone with meals.  Avoid further use of sulfonylurea.  Monitor glucose at facility and adjust regimen accordingly.   Essential Hypertension Blood pressures currently controlled.  Lisinopril held during admission, Ok to resume at discharge.   Hx of Penile Cancer s/p partial penectomy  Urethral stricture Vesicocutaneous fistula  Urinary Retention S/p urethral dilation, bilateral hydrocelectomy in 9/2017. Has had a SPT in the past. Has a vesicocutaneous fistula at site of prior suprapubic tract. Follows with urology, Dr. Underwent urethral dilation on 10/21/22. Recent Urology visit on 12/7 with Foley catheter exchange at that time.  Plan was for cystoscopy in 2 weeks time.  He has had recent hematuria. Continue foley catheter.  Continue Proscar. Had worsening memory issues on oxybutynin. Myrbetriq resumed on discharge.  Follow-up with urology as outpatient as planned.   Generalized Weakness Multiple Falls In the setting of progressive functional decline with multiple co-morbidities and hospitalizations.  Recently discharged to.  Plan to return at discharge for continued rehabilitation.  Chronic LE Lymphedema L > R, noted on previous admission as well. Continue with OP evaluation at Lymphedema Clinic.   Coccyx wounds Evaluated by wound care on 12/12, moisture associated wound to coccyx. Recommend ointment, and ongoing skin checks at facility.   Obesity Continue to encourage lifestyle and dietary modification as able.