Chief Complaint   altered mental status  History of Present Illness     Patient is a 78 years old male with hx of flaccid hemiplegia of R + L side, dysphagia, CAD (s/p CABGx3 in 2018), ESBL infectious endocarditis, OSA, HLD, pAF on Eliquis, hx of hear block s/p pacemaker who is a transfer from  Hospital for altered mentation. Patient is confused on exam and somnolent thus most of history is per outside record. He came to the facility from another location due to having fever, slurred speech, change in mentation. Nursing home reported that patient was well 2 days ago, answering questions appropriately, participating in therapy, and following instruction until the acute change. At the facility, patient had CT head which was negative for acute intracranial bleed. EKG showed afib with paced ventricular complexes. He was found to be Covid positive and had soft blood pressure 93/48. He was given 1L IVF and was started on dexamethasone and azithromycin. He was then transferred to ICU for concern of sepsis. Of note, facility record mentioned that patient was supposed to be on 6 weeks IV antibiotics for infective endocarditis, but somehow was only on 5 days of PO antibiotics.   Initial vitals at facility were notable for blood pressure 95/64 and sat >92% on 2L. Patient was only oriented to self and intermittently followed command but otherwise remained confuse and somnolent. EKG showed afib with ventricular paced rhythm. Labs were notable for Hgb 7.2, plt 66, Cr 3.05, trop 306 (delta trop negative), procalc 21.4, CRP 22.47, and non-elevated lactic acid 1.6. Nurse after speaking to family stated that his mental status had been like this for the past 6 months. Attempted to reach family by phone but was unsucessful.  Of note, he was seen at hospital (admitted 9/22/21-10/21/21) and diagnosed with severe sepsis secondary to endocarditis from ESBL E. Coli (E. Coli sensitive to zosyn) and was treated with ertapenem. He also had UTI with ESBL E. Coli at that time. Document reported persistent delirium secondary to severe illness. Hospital course was complicated by complete heart block suspect from endocarditis with RV PPM placed 9/29/21. He was discharged to SNF on ertapenem to be continued until 11/5/21.  Review of Systems     Unable to be performed due to patient's altered mentation   Physical Exam  Vitals & Measurements  T: 36.3 °C  TMIN: 36.3 °C  TMAX: 36.8 °C  HR: 87  RR: 22  BP: 95/64  SpO2: 92%  WT: 187.4 kg (Dosing)  BMI: 57.8      General:  Alert Eye:  Extraocular movements are intact, conjunctiva pale HENMT:  Normocephalic, Normal hearing, Oral mucosa moist. Respiratory:  Lungs are clear to auscultation, Respirations are non-labored. On 2L NC Cardiovascular:  irregular rate, Normal rhythm, No murmur appreciated. Gastrointestinal:  Soft, no tenderness to palpation throughout,  BS active Musculoskeletal: No peripheral edema. Integumentary:  Skin is warm, dry Neurologic:  A&Ox0, following some commands. Somnolent Psychiatric: Somnolent, unable to further assess  Assessment/Plan      Patient is a 78 years old male with hx of flaccid hemiplegia of R + L side, dysphagia, CAD (s/p CABGx3 in 2018), ESBL infectious endocarditis, OSA, HLD, pAF on Eliquis, hx of hear block s/p pacemaker who is a transfer from Hospital for altered mentation. CT head was negative for acute intracranial bleed. Patient was found to be Covid positive and hypotensive thus was transferred to ICU for further management. Initial vitals at facility were notable for blood pressure 95/64 and sat >92% on 2L. Patient was only oriented to self and intermittently followed command but otherwise remained confuse and somnolent. EKG showed afib with ventricular paced rhythm. Labs were notable for Hgb 7.2, plt 66, Cr 3.05, trop 306 (delta trop negative), procalc 21.4, CRP 22.47, and non-elevated lactic acid 1.6. Encephalopathy is questionable given report from family that patient has been having cognitive impairment/delirium since last admission below. Additionally, ED mentioned that patient was supposed to be on 6 weeks IV antibiotics for infective endocarditis, but somehow was only on 5 days of PO antibiotics. Plan to treat patient empiri   Of note, he was seen at hospitalr (admitted 9/22/21-10/21/21) and diagnosed with severe sepsis secondary to endocarditis from ESBL E. Coli (E. Coli sensitive to zosyn) and was treated with ertapenem. He also had UTI with ESBL E. Coli at that time. Document reported persistent delirium secondary to severe illness. Hospital course was complicated by complete heart block suspect from endocarditis with RV PPM placed 9/29/21. He was discharged to facility on ertapenem to be continued until 11/5/21.   Neuro:  Encephalopathy suspects infectious  Hx of persistent delirium  - CT Head at facility negative for acute intracranial abnormality  - request overread CT head  - continue antibiotics  - consider MRI head to further evaluate stroke  - consider EEG if encephalopathy not improved on antibiotics   Cardiovascular:  ESBL E. Coli Endocarditis on Imipenem at facility  paroxysmal Afib (CHA2DS2-VASC 4) on apixaban  Heart block s/p RV Pacemaker (9/29/21)  HTN  - EKG: afib with ventricular paced rhythm  - Troponin elevated but likely chronic (delta troponin 0)  - reported only on 5 days of PO abx instead of 6 weeks IV abx  - request records from hospital  - obtain TEE to assess for vegetation  - cont vanc and zosyn  - follow blood culture  - hold home apixaban in case of procedure  - hold home lisinopril and amlodipine due to c/f hypotension   Pulm:  Hypoxia suspects secondary to Covid pneumonia   - CXR: bilateral airspace opacities R>L  - cont dexamethasone  - hold remdesivir due to impaired renal clearance eGFR < 30  - urine strep, urine legionella  - RPP, pneumonia panel  - procalcitonin, CRP, ferritin, D-dimer, LDH   GI:  - NPO for now  - bowel regiment   Renal:  AKI on CKD  - UA  - urine na, urine urea, urine creatinine  - renal ultrasound   ID:   Covid Pneumonia  ESBL E Coli Endocarditis  - obtain urine culture  - obtain blood culture  - obtain sputum culture  - urine strep, urine legionella  - RPP, pneumonia panel   - cont dexamethasone for Covid (11/6-p)   Abx:  - vancomycin (11/6-p)  - zosyn (11/6-p)   Endo:  - no acute concern   Heme-Onc:  Thrombocytopenia suspects secondary to infection  Macrocytic Anemia  - obtain iron panel  - obtain B12, folate level   Code: Full  Dispo: ICU  DVT ppx: hold due to elevated INR  Diet: NPO   Patient staffed with attending Addendum by MD, on November 08, 2021 10:22:55 (Verified)    Pt. seen/examined by me 11-6-21, labs/findings reviewed/confirmed by me, images viewed/interpreted by me, and agree with this note by Dr.  Patient, although COVID positive, is remarkably ill from gram negative endocarditis, with recurrence of bacteremia now following completion of primary course, which was complicated by heart conduction issues for which a pacer was placed, now possibly also source of infection.  He is hypoxemic, potentially due to concurrent COVID for which therapy is underway, and although he is alert and awake is almost completely unresponsive, remarkably confused.  Blood cultures are already positive this am, revealing heavy bacteremia almost certainly  from endocarditis.  Prognosis is very poor without removal of pacer and likely valve replacement, however details of his endocarditis are not yet complete, records from facility have been requested and pt is currently too ill to undergo any surgical management.  Have switched zosyn to ertapenem as risk that E. coli is resistant, and have d/c vancomycin.  Total time >31mins cc by me. Date of Admission  11/05/2021   Date of Discharge  11/10/2021   Reason for Hospitalization   Infective endocarditis  Hospital Course       78 y/o male with paroxysmal atrial fibrillation on Eliquis, CAD s/p CABG, ESBL E. coli endocarditis induced heart block s/p R heart pacemaker placement 9/29 (Boston scientific), incomplete treatment duration of endocarditis (~4 weeks out of 6), who was readmitted for septic encephalopathy in setting of ESBL bacteremia. Blood cultures positive for E. coli treated with Ertapenem. Oliguric renal failure appears to chronic given renal US on 11/6 which showed atrophy without obstruction. TEE showed mitral valve vegetation. Patient is not a candidate for definitive surgical management per CT surgery. Son would like DNAR, comfort care. Started treatment for hyperkalemia prior to goals of care discussion. Stopping antibiotics. Family en route.  Discharge Diagnoses      COVID-19   Vaccinated. Treated, on room air.   Infective endocarditis   Treat with IV abx, not open heart surgical candidate given comorbidities. Decision was made to pursue comfort care.   Encephalopathy      1 month prior to admission, concern for septic emboli or anoxic brain injury prior to arrival. Developed Uremia as well  Acute renal failure      Declined dialysis as family decided to pursue comfort care.  Other Diagnoses   Ongoing  No qualifying data  Historical  No qualifying data    Consultants  Medicine Cardiology    Medicine Infectious Disease    Supportive/Palliative Care   Pending Labs  Blood Culture (Preliminary, InProcess, ordered 11/08/2021, 13:10)   Discharge Disposition  Skilled Nursing Facility    Medications  New, Changed, or Refilled Medications  None    Medications to be Continued  acetaminophen (acetaminophen 650 mg, 2 Tablet(s), Oral, q4h, PRN: pain/fever    albuterol (albuterol  HFA 90 2 Puff, Inhalation, q6h, for 30 day(s), PRN: Wheezing, 0 Refill(s)    apixaban (apixaban 5 mg) 5 mg, Oral, bid, 0 Refill(s)    atorvastatin (atorvastatin 2 20 mg, 1 Tablet(s), Oral, At Bedtime, 0 Refill(s)    lisinopril (lisinopril 20 mg 20 mg, 1 Tablet(s), Oral, Daily, 0 Refill(s)    modafinil (modafinil 200 mg) 200 mg, 1 Tablet(s), Oral, qAM, 0 Refill(s)      Discontinued Medications  None  Physical Exam at Discharge  Vitals & Measurements  T: 36.7 °C  TMIN: 36.7 °C  TMAX: 36.8 °C  HR: 83  RR: 36  BP: 138/71  SpO2: 94%      General:  Resting, non responsive HENMT:  Fixed pupils Respiratory:  No chest rise Cardiovascular:  No peripheral edema. Gastrointestinal:  Non-distended Musculoskeletal: Absence of movement Integumentary:  Skin is cold Neurologic:  Fixed pupils, no response to verbal, tactile stimulation Psychiatric: Unable to assess  Time Spent  >30 minutes       Nursing/Other Orders   Regular Diet. Ordered on 11/10/21 12:45:00 Meal Start Time Breakfast 0700 to 0900   Sofcare Static Air Seat Cushion. 11/08/21 10:31:00, when out of bed to chair   Fall Precautions. 11/05/21 20:08:27. Order comment: order placed from nursing documentation CLIN_FALL_RISK   Code Status. Code Status Description: DNAR (Do Not Attempt Resuscitation)   Oxygen Instructions. 11/10/21 12:45:00, Routine, Instructions Titrate to comfort. No O2 Saturation Monitoring. Order comment: