Reporte zur Charge BG3275

Symptomtext

Patient is a 78 y.o. female who presented from assisted living on 11/1/2023 with acute encephalopathy after being found down in her bathroom. Assessment and Plan Acute metabolic encephalopathy resolved TBI - multifactorial from dehydration, possible concussion and probable UTI - CT head/max-fac/chest/abd pelvis 11/1 w no acute fx, visceral injury - Treat underlying etiologies as below - more alert and oriented on 11/5 -Repeat CT h 11/4 as pt appeared more confused neg UTI Patient w pyuria, appears symptomatic per questioning -afebrile, WBC elevated at 14.39 on admit -Started on cefazolin: given confusion, leukocytosis needs broadened to rocephin -completed abx Acute respiratory failure hypoxia, pneumonia -COVID postiive 11/6/23 -started decadron 6 mg po daily given hypoxia for 10 days can do shorter course if Likely in setting of atelectasis from poor ambulation. -CTA ruled out PE, RLL, RML infiltrate pna v atelectasis - stop zithromax due to covid positive Left lower extremity cellulitis-ruled out Chronic venous stasis more likely than cellulitis Erythema and reddness on L LE -ruled out vte with duplex -encourage oob Fall - unclear etiology, pt unable to give history, suspect mechanical in nature - imaging negative for acute fracture or injury - PT/OT: rec up to 5, CM following for SNF dc - R Arm xray 11/5 as she reporting more pain Dehydration Mild rhabdomyolysis CPK 495 on admission and tachycardic -Improved with IVF Elevated troponin Hx of severe aortic stenosis Suspect demand from tachycardia and fall Trop 49->60->54 -Echo w EF 70%, has elevated LA pressure, s/p AVR -CT PE neg Diabetes mellitus type 2 with neuropathy Controlled: A1c 6.4% on 8/7/23 - hold metformin and glimepiride while inpt - SSI prn - cont gabapentin for neuropathy: reviewed meds and on 800mg tid outpt, reduced to 400mg tid Essential HTN BP reviewed,fairly well controlled - cont losartan and metoprolol w hold parameters History of CVA - cont plavix Major depression - cont bupropion with prn atarax Morbid Obesity Body mass index is 42.81 kg/m?. -Needs aggressive lifestyle modifications as outpatien