Age: 50.0
Sex: M
Vaccine: COVID19
Symptoms: Vitamin B12 deficiency, White blood cell count normal
Clinical narrative: 52-year-old male with PMH significant for T2IDDM, DVT/PE, and polyneuropathy who presented to hospital on 09/28/2022 from home with chief complaint of fall, found to be hyperglycemic by EMS. On presentation the patient's blood glucose was 891 without anion gap or acidosis. HCT was done showing no acute process. CXR showed RLL opacity. He was given IVF, started on insulin infusion, and received doxycycline/ceftriaxone for possible CAP. Concern for CAP was low as patient was afebrile with normal WBC and differential throughout admission. Empiric antibiotics were discontinued. Patient had reportedly been out of his medications including insulin for one month. HbA1c was 13.0. Endocrinology was consulted and Insulin gtt was changed to subcutaneous insulin. Diabetes was difficult to manage due to dietary indiscretions. Per dispense report in 6/2022 he was prescribed lithium and bupropion by psychiatry, patient states he did not like the side effects and did not take them. Does not want to be restarted on these medication. Psychiatry was consulted, no new medication advised.  Patient used innapropriate language towards staff, he was presented Safety and respect contract and agreed with the contract.   Prerenal AKI was present on admission with creatinine to 1.45 and hyperkalemia to 5.3. Resolved with IVF and glycemic control.  Patient was also found to have significant vitamin B12 deficiency with vitamin B12 < 146, likely contributing to polyneuropathy and frequent mechanical falls. IM vitamin B12 1000 mcg QD was initiated, and patient will be discharged with prescription for oral vitamin B12.  Patient has h/o DVT/PE, was off anticoagulation for months. LEVD ordered and demonstrated chronic RLE proximal DVTs and acute left peroneal vein DVT. Patient is not an ideal candidate for anticoagulation due to falls, noncompliance.  Hematology/oncology was consulted and recommended lifelong Eliquis at a prophylactic dose (2.5 mg BID) to decrease risk of bleeding, and advised repeat LEVD in 2 weeks.  The morning of discharge patient complained of nasal congestion, he denied other respiratory symptoms, was afebrile. Covid test ordered per patient request.  Psychiatry evaluated patient and cleared for discharge.  Given frequent falls, PT/OTconsulted. PT made several attempts to work with patient, had difficulties evaluating patient due patient's refusal. PT referred to OT note from 9/30 who recommended home with supervision. Patient states he has a roommate who will be able to help. RW and shower chair ordered Patient repeatedly asked for discharge. He was stable for discharge and CC contacted and assisted with discharge and DMEs. Skilled care, home PT,OT, visiting nurse and dietitian ordered. Covid test resulted positive after discharge. Patinet had Janssen vaccine on 5/25/21. Dr notified son of result, son was upset and wanted to speak with attending. I called son and discussed test result, he was frustrated and angry, used abusive language, asked to have hospital administrator call him. Explained that his father had no respiratory symptoms or complaints in the afternoon when I reevaluated him, and efforts were made to discharge him yesterday per his request. At the end of the conversation son apologized for language used and would appreciate a call from hospital administration.  Discussed with hospital administrator Dr and with infectious disease specialist who recommended monoclonal antibody or antiviral tx if patient elects to get treatment for Covid 19. Would avoid paxlovid given eliquis.  Readmission for remdesivir is not necessary, but if patient elects to return to the hospital will prescribe remdesivir. Provided son with these recommendations and gave information re urgent care near patient's home where mAb can be administered (Get well urgent care).  I called patient to follow up on decision re treatment, patient states he does not have nasal congestion, sore throat, cough but if he can have a ride would come to the hospital if he has a private room. Called son, son states he will see how his father feels and will call urgent care tomorrow, he is not sure about treatment and possible side effects since his father has no symptoms.  ED notified of possible readmission for remdesivir.