Per MD Clinical Note 3/14/21, "Further discussion with his daughter today-patient has not been able to walk and has had unclear mentation for approximately 8 years after an alcohol related decline.  Was in a nursing home until he moved into his parent's house.  His mother actually passed away and December and his stepfather has been trying to take care of him since.  Patient may periodically stand but is a house where he is pretty much confined to his bedroom and bathroom.  Patient received his COVID-19 vaccine at the prescription shop 03/04/2021 and since then he has had a steady decline starting with aches and pains to increased weakness and confusion and then collapse which brought him to the emergency room.   Assessment and plan Syncope with altered mental status/toxic metabolic encephalopathy  Acute on chronic respiratory failure with hypercapnia  Sepsis  Supratherapeutic Coumadin level INR greater than 9  Anemia  Small hemoperitoneum  Hypotension  Chronic pain syndrome  COPD  UTI  Enteritis  Subsegmental atelectatic changes with nodule left lower lobe the-recheck 3 months  Cirrhosis  Nicotine dependence  CHF-chronic diastolic  Functional quadriplegia  One week post COVID-19 vaccination  Agitation  Other:  GI bleed, PAD, hypothyroidism, history of DVT left leg, neuropathy, depression, BPH, CAD, subdural hematoma, acquired thyroid disease, GERD, Wernicke    -continue to trend the LFTs downward.  Is on Precedex currently to allow him to further recover.  He was using accessory muscles and poor inspiratory effort today but maintaining his oxygenation.  BiPAP was reinstituted to avoid CO2 retention.  One possibility is that the patient consumed a significant amount of Tylenol due to the discomfort exacerbated with the cirrhosis.  LFTs are trending upward still.  -hypercapnia patient consume both the benzodiazepine and morphine supported initially for the 1st 36 hours with BiPAP.  Has had periods where he is off and answers appropriately.  -consider rescanning in a.m. To further evaluate the hemoperitoneum.  Continue broad-spectrum antibiotics and hemoglobins.  Patient is NPO until further delineation  Patient is a functional quadriplegic year and at home is fairly dependent on his stepfather for a total care family seeking long-term care which may mentally benefit the patient with broadening his activities                       -blood cultures pending. " Per Clinical note 3/13/21, "Assessment and plan   Syncope with altered mental status/toxic metabolic encephalopathy  Acute on chronic respiratory failure with hypercapnia  Sepsis  Supratherapeutic Coumadin level INR greater than 9  Anemia  Small hemoperitoneum  Hypotension  Chronic pain syndrome  COPD  UTI  Enteritis  Subsegmental atelectatic changes with nodule left lower lobe the-recheck 3 months  Cirrhosis  Nicotine dependence  CHF-chronic diastolic  Functional quadriplegia    Other:  GI bleed, PAD, hypothyroidism, history of DVT left leg, neuropathy, depression, BPH, CAD, subdural hematoma, acquired thyroid disease, GERD   -patient is more awake and wakening a hourly on BiPAP will remove 1 fully alert and functioning will use BiPAP overnight.  Nicoderm avoid tobacco.  NPO unless ammonia level is elevated.  Continue empiric antibiotics.  Last evening required to units packed RBC.  If hypotensive and or increase in anemia will rescanned.  Monitor for DTs and withdraws.  Was advised by the nursing staff patient is following orders.     Functional quadriplegic rotation every 2 hours had bed at 20-30 degrees to avoid aspiration.  Patient and his family confirm DNR status.  Long-term placement required as his stepfather is unable to care for him without assistance.  Anticipate restarting diet in a.m..  One fully alert will ascertain if this was delivered or accidental.  Drug screen was positive for both benzos and morphine.  He has been and prescribed the morphine.  The dual combination liver failure patient with depression likely ill-advised     "