Reporte zur Charge 2EN6208

Symptomtext

Date of Admission: 1/15/2022 Chief Complaint: Acute hypoxic respiratory failure Source of Information: Available medical record History of Present Illness: Patient is a 72-year-old female with a past medical history of asthma, hyperlipidemia, hypertension, presented to the hospital on 1/15/2022 for altered mental status. Patient is accompanied by her husband and daughter. Entirety of history is obtained from chart review as well as conversation with the daughter and husband as the patient is currently sedated and on the ventilator. Patient was noted to arrive to the ED with an SPO2 of 77% on room air. She was noted to be alert and oriented x0, nonverbal. Husband tells me that in the last 2 months the patient has had intermittent episodes where she "stares off into space". The daughter states that the patient also starting 2 months ago has had lapses in memory. This morning at approximately 4 AM, the husband woke up and noted that the patient was nonverbal. Family denies any head trauma or recent falls with the patient. She does not have a history of strokes or seizures. In the ED the patient presented with a blood pressure 200/105, HR 102, temp 98, RR 17, SPO2 77% on room air. She was noted to be positive for COVID 19. Imaging was obtained showing a new left lateral ventricle effacement with 9 mm rightward midline shift. Was admitted to ICU for further evaluation with consults made to neurology and neurosurgery.