Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Pneumonia streptococcal, Procalcitonin increased, SARS-CoV-2 test positive, Sepsis, Toxic encephalopathy
Clinical narrative: HOSPITAL COURSE: Briefly, this is a 64-year-old female with multiple sclerosis, who was admitted on 1/8/2022, for worsening confusion and weakness in setting of COVID and bacterial PNA.  Treating acute encephalopathy secondary likely toxic/metabolic. For more detail, including PMH, PSH, PFH, Social Hx and further info please see admission H&P.  Hospital course dictated by problem: Acute hypoxic respiratory failure due to bacterial PNA Sepsis due to pneumonia, resolved Right lower lobe bacterial streptococcus pneumonia COVID-19 pneumonia Was vaccinated 4/2021, but overdue for booster.  COVID positive in clinic, estimated around 12/31. Was seen in clinic then as was having weakness with one fall at home  Had COVID treated with monoclonal antibody 1/6/22. Despite this continued to have progressive weakness, confusion and then developed shortness of breath. 1/8 presented to ED with weakness and confusion hypoxia requiring supplemental O2 via NC at 6L.   CTPE neg for PE.RLL consolidation. + PCT, Urine St pneumo agn +.Studies c/w bacterial PNA w/ elevated procal, imaging. Per ID felt respiratory issues were not related to COVID PNA, more so bacterial PNA and 2/2 PTA sedative meds (tramadol, etc).- Per ID: her CT shows a lobar infiltrate but not diffuse infiltrates c/w COVID Would stop Decadron and monitor, if she appears to have worsening component of viral PNA (hypoxia, etc) would resume - does not appear her PTA Zeposia is assoc w/ more severe COVID sxs (per ID), ok to cont per neurology Therefore decadron was discontinued. Respiratory status has been stable since stopping decadron. Abx: was on rocephin, doxycycline. Doxy d/c 1/9 as pneumococcal urine Ag positive.  Patient was fully treated for her pneumonia with ceftriaxone, stopped at time of discharge.  ID signed off.  Patient was stable on room air at time of discharge.  She was seen by PT who did clear her to return home.  Follow-up with PCP in 2 weeks.  Needs follow-up imaging within 4 to 6 weeks including to rule out infiltrates also evaluate pleural effusions.  Patient understands if she has any recurrent infectious symptoms to return immediately.  Discharge plan was discussed in detail with her husband via phone.  Good questions were asked and all were answered.   Bilateral pleural effusions, hypoalbuminemia CT w/ bilateral pleural effusions - this likely related to hypoalbuminemia - s/p Albumin 12.5 mg q30min x 2 doses as hypotensive, hypoalbuminemic and bilateral effusions. -Consider outpatient chest x-ray in 4 weeks   Acute metabolic/toxic encephalopathy -resolved In setting of above. Mild dementia at baseline and w/ MS hx. Bacterial PNA and COVID causing encephalopathy. - Head CT negative for acute intracranial processAlso more susceptible given PTA sedative medications such as tramadol. Tramadol initially held to help.  Tramadol was slowly resumed by 1/10 improving. Alert to person and place. Said year 2021 but redirected to recent new year and later recalled accurate year.1/11- sl confusion re earlier events .  By day of discharge she appeared to be at her baseline mentation without any obvious confusion.  Tramadol had been continued on a slightly lower dose.  Advised to continue that at home.  PCP can additionally eval   Generalized weakness-diffuse generalized weakness likely secondary to COVID-19 with acute worsening also contributed by her baseline MS.  PT OT consulted.  PT cleared to go back to her home, her husband is able to give her 24/7 supports, although she remains a chronic high fall risk.   Multiple sclerosis-chronic-has outpatient neurologist,home dose Zeposia and Baclofen Recently had battery of MRIs and per husband MS considered stable.,  She was maintained on PTA tramadol.  Follow-up - needs to reSchedule w OP Neurologist (was supposed to be on 1/10)    History of cognitive impairment secondary to MS Per husband at baseline alert to person, place and time.- Not on any meds. F/u Neurology   History of generalized anxiety disorder, chronic benzodiazepine use-patient maintained on PTA Cymbalta Per husband she takes 2 mg of Valium usually every afternoon but little other than that.   He asked about dosing and advised if wanted they could decrease to q. OD.  She has a as needed Xanax prior to MRI as ordered but does not take that. Further management per psych vs primary care.   History of chronic opiate use, chronic low back pain- reports she has chronic low back pain has been on tramadol for a long time, reported as she became more clear that her back pain was increased here, wants her past tramadol resumed, seems Encephalopathy contributing to confusion regarding her reported dose tells me she did not take it daily but just intermittent a few doses a day max when she needed it.    Appears PTA she takes 100 a.m./50 p.m./150 PM.  That is higher than I would recommend.  At time of discharge she seemed to be stable with mild pain on the lower tramadol dose of- 50mg am, 50mg 2pm, 100mg available as prn at bedtime.  I recommend continue that for now.  charted hx of alc abuse. Recommend follow-up with TC pain clinic re other modalities    Hx UTI: 2 weeks ago -> rx antibiotics without improvement.