Unusual Symptoms

Doctor's File Notes UCSF Medical Center Discharge Summary February 23, 2014

[Patient] is a 72 y.o. male patient with a h/o depression s/p ECT and numerous psychiatric medications, baseline tremor d/o NOS, benign functional adrenal tumor, elevated PSA with 2/6/14 TRUS showing 2/8 specimen with focal high grade prostatic intraepithelial neoplasia, and recent hip fx who was BIBA after being found supine, awake, but naked and disoriented in his apartment.

Patient could not provide history due to AMS. Per EMS REPORT, they responded to a call from his neighbor to his residence for a wellness check. His neighbor reported that the patient has been "declining and not taking care of himself, unable to walk because he's so weak" for the past month and that he had not seen his neighbor for 1 week. His neighbor tried to check on him but [patient] did not answer the door. SFPD had to use forcible entry to gain access in his apartment. He was found in a supine position on his carpeted floor, naked next to his computer. The patient was noted to have multiple wounds on his lower back, both feet and R elbow. His apartment was in disarray, cluttered, and mice were seen running around the kitchen. He was confused with a GCS of 14 and unable to recall the year or event. He couldn't answer questions and only repeated his date of birth. He was able to deny having any chest pain, SOB, HA, dizziness, blurred vision, or NV.

His neighbor was initially in the ED and brought along the patient's home medications, which included numerous psychiatric medications. However, there was no mention of pills being around him when he was found down. Primary medicine unable to contact neighbor. Sister-in-law noted that pt was in his USOH 1 week ago and was fully independent at home. In the ED, he received 2L NS and remained HD stable, awake but disoriented and unable to engage in a conversation.

[Patient's] AMS was initially thought to be multi factorial. He initially presented with a mixed acid/base derangement, profound hypermatremia (Na 152), and uremia in the setting of acute AKI. He had a non contrast head CT that was performed which was unremarkable. At the time of admission he was resuscitated with D5W at 150 ml/hr for 20 hours which resolved his hypernatremia and acid/base derangements. All his psychiatric medications were held during this hospitalization given concern of possible med side effect precipitating his AMS. Furthermore a lumbar puncture was performed on HD#2. CSF analysis and culture were overall negative. As the patient's metabolic and electrolyte derangements resolved the patient began to return back to his baseline; however, continued to not have any recollection of the inciting sequence of events that brought him to the hospital. Psychiatric medication side effect/over ingestion was thought to be the primary cause of the patient's admission. The primary team discussed his case extensively with his outpatient PMD Dr. JH, and psychiatrist Dr. AK. Follow up appointments were made with both physicians soon after discharge. Patient will need to f/u especially to reconcile and adjust his extensive psychiatric medication regimen. He was discharged to SNF with the instruction to hold all psychiatric medications until he sees his outpatient psychiatrist.

#AG Metabolic Acidosis
He presented with an anion gap metabolic acidosis thought to be 2/2 starvation ketoacidosis given an elevated serum beta-hydroxybutyrate and a urinalysis positive for ketones. His acidosis resolved with IV D5W resuscitation.

#AKI
Patient most likely was volume depleted in the setting of being down for an extended period time without any PO intake as seen with an elevated urine Osm and hypernatremia. Patient's BUN/CR ratio > 20 also supports AKI 2/2 volume depletion. His AKI resolved on HD#2 with IV D5W resuscitation. He does have a history of CKD per his PMD.

#Cellulitis
Patient presented with scattered areas of skin breakdown and erythema consistent with soft tissue infection. He was initially treated empirically with IV Vancomycin and later during his hospitalization switched to PO septra BID, he will need a 10 day course, last day 3/1/14. Blood cultures on admission remain negative.

#Transaminitis
Patient's elevated liver enzymes at initial admission were thought to be 2/2 side effect of his multiple psychiatric medications. The patient had a RUQ ultrasound which was otherwise unremarkable.

#Mildly Elevated CK
Patient's elevated CK is most likely 2/2 muscle breakdown from being immobile on the ground for an extended period of time. His elevated CK resolved with IVF fluid resuscitation.

#Hyperreflexia/Clonus
Patient has a history of abnormal prostate biopsy. Patient's clonus and hyperreflexia concerning for an UMN lesion particularly in the spine. Neuro consulted and recommend MRI sagittal survey to rule out spinal myelopathy vs stenosis. However, his Hyperreflexia and clonus resolved as his metabolic derangements resolved making a structural defect very unlikely.

#Anemia Patient initially presented with a Hgb of 9.9 and MCV of 93. During the course of his hospitalization his Hgb dropped to 7.8, likely due to frequent phlebotomy. His serum iron was notably low at 33. His serum transferrin and ferritin were pending at the time of discharge. Total protein and albumin showed no gammap gap. SPEP and UPEP to assess for MM pending. Patient will need a colonoscopy screening as an outpatient (last done here on 12/20/2011) and iron resupplimentation. Folate and B12 levels were also pending. Patient also taking methylcobalamin at home.)

#L hip fracture 9/20/2013 s/p fixation
Patient intermittently endorsed pain in his hip and lower back. He recently underwent repair for a L hip fracture in Sept 2013 and spent the next few months at a rehabilitation center. Opiates and NSAIDs were not given due to his AMS and AKI. His pain was treated with a lidocaine patch. Of note, patient did show transient signs of clonus and hyperreflexia in his lower left extremity but resolved with resolution of his metabolic derangements.