Hospitalized (1.27.22 - still admitted currently); COVID-19 positive (1.26.22); fully vaccinated PLUS Booster - pfizer x3 1/27/22 H&P:  CHIEF COMPLAINT: AMS (altered mental status) ASSESSMENT / PLAN: Patient is a 64 yo M with h/o alcoholic/Hep C cirrhosis s/p liver transplant in 2013, complete heart block s/p pacemaker, Afib/aflutter (Eliquis), CKD3, COPD, Bipolar disorder, and CHF who presents on 1/27 with cough x2 weeks and weakness/falls/confusion x 1week.   #AMS Patient reportedly more confused than baseline over the past couple days and was A&O x1 on admission.  Quickly improved and was A&O times 2-3 on evaluation.  Concern for polypharmacy versus infection versus COVID symptom. - blood, sputum cultures, UA pending - Hold home Arpiprazole, Lamotrigine, Tizanidine, Gabapentin, and Baclofen until AMS resolves - daily cmp, cbc - Folate, B12, CRP/Sed rate pending    #Acute on Chronic Generalized weakness #Multiple falls #Acute headache Patient uses walker intermittently at baseline and has multiple falls per year.  Weakness has acutely worsened over past week.  Suspect deconditioning versus COVID symptom. CT head was negative for acute pathologies - PT/OT - Acetaminophen PRN for pain   #Concern for diskitis # Chronic back pain # h/o L4/L5 fusion Pt received an MRI 10/2021 due to worsening of chronic back pain, and findings were concerning for L3 - L4 diskitis/osteomyelitis. F/u with ID with plans for an outpatient biopsy. Patient has chronic back pain and muscle spasms for which he receives treatment through his PCP.  Also follows with pain clinic. He is on home Percocet 7.5 q.6, tizanidine, and gabapentin 600 TID. - ID, IR consult for biopsy - Continue Oxy 7.5 q6hrs PRN for pain - Hold tizanidine, gabapentin for AMS on admission    #COVID #COPD Diagnosed 1/26.  Vaccinated.  Had productive cough over the past 2 weeks.  Became hypoxic shortly after admission requiring 2 L nasal cannula. Out of Remdesivir window.  - Started Decadron 6  - Continue Guaifenesin, tesslan perles PRN - Continue Tiotropium, albuterol, symbicort PRN - continuous pulse ox   #AKI on CKD3 Cr 3.28 on admission; baseline 2 - 2.3. Suspect pre-renal secondary to dehydration. - hold home Torsemide   #Aflutter/Afib #Complete heart block s/p pacemaker - Hold Eliquis for potential biopsy   #Alcoholic/hep C Cirrhosis s/p transplant Transplant through HCF in 2013. Had prior concerns for recurrent HCV, acute Hep E; now resolved/stable. Chronic, mild transaminitis and elevated ALP since hep E infection. - Continue home mycophenolate and cyclosporine   # Bipolar disorder Pt is on home Arpiprazole, Lamotrigine, and Venlafaxine. - Hold Arpiprazole and Lamotrigine for AMS - Continue home Venlafaxine   # HFpEF # HTN LVEF 60%. No current signs of volume overload. - Continue home carvedilol 25, hydralazine, and imdur. - hold home Torsemide for AKI   #Hypothyroidism: Continue home levothyroxine   #GERD: Continue pantoprazole   #BPH: Continue Tamsulosin   #h/o T2DM  HbA1c 6.2. No current medications.   Diet: NPO DVT prophylaxis: home Eliquis Full Code Dispo: Pending evaluation of weakness and recent diskitis HISTORY OF PRESENT ILLNESS: Patient is a 64 y.o. male who presents today with worsening weakness and to mechanical falls over the past week.  He notes that he developed a cough productive of yellow sputum around 2 weeks ago.  No dyspnea, chest pain, congestion.  About 1 week ago, he notes increased fatigue, diffuse weakness, and mild confusion.  He uses a walker intermittent at baseline and has a history of falls; approximately once every month or so.   He reports walking up a parking lot brand when he fell backwards and hit his head on the ground.  He does not believe he lost consciousness, but he is unsure.  He thinks he was on the ground for a couple minutes before standing and driving home.  No prodrome or postictal state.  No focal deficits.  He has had a stable headache since hitting his head.  In his 2nd fall, his leg became tangled and he fell to the ground.   Currently, he still feels weaker than baseline and he has a severe headache centered on the spot where he hit his head.   He has a history of alcoholic and hepatitis cirrhosis status post transplant in 2013. He regularly follows up with the transplant doctor and has no current concerns regarding his liver.  He also has a history of third-degree heart block with a pacemaker.  He was previously diagnosed with type 2 diabetes, but his glucose has been controlled without medications. He is a half pack per day active smoker.  Denies any alcohol or drug usage.   Review of Systems Constitutional:  Positive for fatigue and fever. Negative for chills.  HENT: Negative for hearing loss and ear pain.  Eyes: Negative for pain and visual disturbance.  Respiratory:  Positive for cough. Negative for shortness of breath and sputum production.   Cardiovascular:  Negative for chest pain and palpitations.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Negative for difficulty urinating, dysuria and frequency.  Musculoskeletal:  Positive for falls. Negative for neck pain, back pain and joint pain.  Neurological:  Positive for headaches. Negative for light-headedness, numbness/tingling and weakness.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Skin:  Negative for rash and wound.  OBJECTIVE: BP 134/58  | Pulse 85  | Temp 36.6 °C (Axillary)  | Resp 18  | Ht 1.854 m  | Wt 101.9 kg  | SpO2 92%  | BMI 29.64 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance.  HENT:     Head: Normocephalic.     Comments: 1.5 inch area of ecchymosis with mild excoriations on R posterior scalp. No laceration or active bleeding.    Mouth/Throat:     Mouth: Mucous membranes are dry.     Pharynx: Oropharynx is clear.  Eyes:     General: No scleral icterus.    Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Normal range of motion and neck supple. No rigidity.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: He is alert.     Motor: No weakness.     Comments: AxO x2 (person, place, month but not day). Good historian. Answers all questions appropriately.     1/28/22 ID consult: Reason for Consult:  Concern for diskitis and liver transplant patient Inpatient Consult to Infectious Diseases Performed by: MD Authorized by: 2nd MD  Assessment: 1. Status post liver transplant - transplant in 2013 due to cirrhosis. Follows with a HCF. 2. Concern for diskitis.  Patient has hardware in place at L4/L5.  MRI in October due to worsening back pain with concern for L3-L4 diskitis/osteo.  Outpatient biopsy had been planned 3. Altered mental status - reportedly A&O x1 on admission now appears to be baseline. 4. COVID-19 - vaccinated and boosted.  Diagnosed 1/26.  Hypoxic requiring supplemental oxygen.  Reportedly has had cough for 2 weeks 5. Leukopenia -unclear if this is due to comorbid rhesus side effect of immunosuppression. 6. Immunosuppressed   - On cyclosporine and mycophenolate 7. AKI on CKD 3.  Baseline creatinine 2-2.3 elevated at 3.28 on admission 8. Generalized weakness/falls 9. Chronic obstructive pulmonary disease   Plan: 1. Agree with IR consult for biopsy for diskitis/osteomyelitis   - Please send for tissue pathology and cultures 2. Would not start antibiotics at this time 3. Agree with Decadron given hypoxia 4. Not a candidate for remdesivir given creatinine clearance 5. Recommend primary service contact HCF regarding the patient's immunosuppression   HPI: Patient is a 64 y.o. male with a past medical history significant for liver transplantation secondary to cirrhosis.  He is currently hospitalized at a local Hospital under the care of the hospital Service.  He presented with concerns of weakness, mechanical falls, and cough productive of some yellow sputum.  Patient reports he developed a cough for about 2 weeks ago, for the past week he has noticed increasing fatigue some weakness and mild confusion.  He does intermittently use a walker at baseline and has a history of mechanical falls typically occurring once every month or so.  He has fallen twice within the past 2 weeks.  He states that he does feel weaker than he typically does.  The patient was seen in Infectious Disease Clinic on 01/25/2022 due to concerns of an abnormal MRI concerning for diskitis/osteomyelitis of the spine.  Patient does have a history of an L4/L5 fusion and has had spinal injections in the past but no recent spinal instrumentation.  He underwent MRI imaging due to ongoing back pain which is what revealed changes compatible with osteo/diskitis.  Plan had been for him to undergo IR biopsy as an outpatient, however, he was hospitalized shortly after his clinic visit. Patient's initial lab work did not display a leukocytosis, creatinine was elevated from baseline at 3.28, proBNP elevated at 13,662, CRP elevated at 90.5.  Peripheral blood cultures obtained with no growth to date.  Reportedly the patient was confused upon admission was only alert and oriented x1, this appears to have resolved.  Today he states that he continues to have cough and does still feel weak compared to his usual baseline.  With regards to his transplant he follows with HCF he states there has been no concerns with his transplant currently but he has had episodes of rejection requiring steroids in the past. Objective:   Vitals: BP 134/78  | Pulse 69  | Temp 36.5 °C (Oral)  | Resp 16  | Ht 1.854 m  | Wt 101.9 kg  | SpO2 93%  | BMI 29.64 kg/m²   Wt Readings from Last 4 Encounters: 01/27/22 101.9 kg 01/25/22 106.3 kg 01/11/22 97.5 kg 12/15/21 97.5 kg     Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is ill-appearing. He is not toxic-appearing.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal. No congestion.     Comments: Nasal cannula in place    Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: No oropharyngeal exudate or posterior oropharyngeal erythema.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.  Cardiovascular:     Rate and Rhythm: Normal rate.     Pulses: Normal pulses.  Pulmonary:     Effort: Pulmonary effort is normal.     Comments: Recurring supplemental oxygen.  Air entry equal bilaterally.  Scattered crackles present. Abdominal:     General: There is distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: No deformity or signs of injury.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not jaundiced.     Findings: No bruising.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.     Comments: Strength is 4/5 in the lower extremities bilaterally.  Some complaint of hyper sensitization compatible with neuropathy.