Present Illness and Medical Treatment (relating to current admission). This would include a synopsis

Present Illness and Medical Treatment (relating to current admission). This would include a synopsis of the physician’s initial assessment/impressions (H&P), and the medical progress of the patient during his/her stay. A. Diagnosis and Treatment documentation (date and method of admission, admitting diagnosis, condition necessitating examination and treatment) and medical treatments. **Help me put this information below into a professionally written paper about my patient’s medical treatment and progress through hospital stay.** Medical treatments: After ICU admission On January 21, 2025, patient remained intubated and sedated overnight. She also remained on norepinephrine which was weaned from0.05 to 0.02. An enema was also given with no observed bowel movement, but otherwise no other acute events were noted overnight, not any evidence of seizure activity was observed her liver enzymes were noted to be up trending. Action plan: Patient currently on Keppra 1000mg twice daily; continue to monitor closely for evidence of seizure activity.. Wean ventilator settings as tolerated Neurology following Monitor hemodynamic status Patient is now on full ventilator support. Fentanyl, midazolam and levophed infusing. No seizure activity yet. 400cc urine output, 500cc LR bolus given for elevated lactic acid. Levophed weaned down from 0.05 to 0.02. No BM. Vent settungs improving. Patient no longer requiring vasopressors for map>65. Plan: Currently on Versed and fentanyl, wean down as tolerated. Continue Unasyn for aspiration pneumonia, Daily chest xray, ABG, CBC, CMP, magnesium, phosphorus. Bowel regimen: fleet enema, Dulcolax suppository, digital rectal exam for disimpaction. Continue home dose of levothyroxine 125 mcg. Started on tube feeds: jevity, insulin sliding scale. Neurology note: Reason for consult: seizure Labs and imaging: CT head shows overall cerebral atrophy. CTA chest confirms aspiration pneumonia possible multifocal pneumonia. EEG on 1/21/2025 showed moderate to severe encephalopathy with no epileptiform activity noted. Blood pressure 141/51. Recommend: continue on Keppra 1000 b.i.d. Donepezil medication for dementia on hold for intubation and sedation of the patient. On 1/22/2025: Patient was retaining urine. Bladder was scanned x2. Straight cath with 400 cc urine output. Patient also had 3 loose stools. Patient is still vented and sedated, on versed and fentanyl. Does not open eyes to verbal/noxious stimuli. Versed and fentanyl discontinued, patient is started on IV precede and is on minimal vent settings. Will attempt to perform SBT and evaluate respiratory status. Wound/skin consult: Patient had a low braden score which prompted wound/skin consult. On 1/23/2025: Patient remains intubated and was monitored off of sedation. Patient remained hemodynamically stable. Will attempt to CPAP and extubate in the morning. Patient wakes up to verbal stimuli, withdraws from painful stimuli in all extremities. Per group home staff who is present at bedside, she wouldn’t be able to follow commands at her baseline. Patient has not been on sedation since last night. Did well on CPAP, plan is to extubate her today. Plan: Extubate, continue tube feeds (also consult for SLP evaluation), continue levothyroxine 125 mcg and transfer to general medical floor. 1/23/2025 during midday: Patient is on 4 L nasal cannula and was extubated. She was transferred on a heart monitor and tolerated the transfer. On 1/24/2025: Abominal xray done to verify placement of nasogastric tube. Tube retracted and placement confirmed at 51 cm. Patient currently extubated and moved to PCU. Shes awake but not following commands which is her baseline. She is moving without difficulty and continues to be on antibiotics for aspiration pneumonia. Patient’s sister and her husband were present at bedside today to discuss patient’s quality of life which has been worsening for the past 1.5 years. She was intubated this admission, needed pressors support and currently hypertensive as seen in PCU. Sister wants to discuss hospice. Social work was consulted and connected the family to discuss this matter. AKI resolved and is receiving free water flushes 240 tid and her creatinine is 0.69. Fecal impaction and constipation resolved. HTN still high: added amlodipine 5 mg and labetolol 10 pm, hold meds if hypotensive and add fluids. Consult SLP evaluation. SLP consult results: Patient is edentulous and presents with symptoms of oropharyngeal dysphagia based on clinical bedside evaluation. She was noted to have wet breathing quality and increase in breath work during PO trials. It was reported that this is not her baseline by her caregiver. SLP tried to have the patient cough but patient denied and further PO trials were deferred due to not following commands. Contributing risk factors include deficits in cognition and respiratory swallow coordination, intubation, potential sensory deficits related to dementia and COPD, reduced mobility and difficulty following directions. Recommend: continue NPO with just NG tube feeds. Regular oral care every 4-6 hours to decrease bacteria overgrowth. On 1/25/2025: Patient today is not oriented and is having tremors. One to one sitter is at her bedside and patient still has NG tube. Aspiration pneumonia resolving. Break through seizure resolving. Blood pressure better controlled this morning. On 1/26/2025: Patient’s sister as decided on hospice care. No changes. On 1/27/2025: Hospice paperwork signed. Discharge planning started. Oropharyngeal dysphagia still valid. Patient had immediate cough with thin liquids via spoon. Multiple swallows needed w/nectar thick liquids. Instrumental swallow study via MBS recommended to visualize oropharyngeal swallow function, determine least restricted diet and appropriate plan. Patient is NPO for MBS tomorrow. Family wants patient to have PEG tube. Patient NPO for PEG tube placement tomorrow. A repeat for speech evaluation was ordered. On 1/28/2025: Patient has not had an oral diet or been able to swallow for one week. She is being seen for general surgery for PEG tube placement today for dysphagia for tomorrow. Second SLP evaluation: MBS Findings include Patient has grossly functional oropharyngeal swallow for thin liquids and puree texture. Recommendations: d/t plan for hospice, an oral diet would align better with patient goals rather than PEG tube. PEG tube would not increase patient’s comfort or quality of life. Recommend diet: puree texture, thin liquids vias sippy cup. Meds: crushed in puree; 1:1 assistance with feeding. Fed only when accepting PO intake. Small single sips, small single bites, slow rate, upright 90 degrees and 30 mins after, repositioning to keep head in neutral position as able. On 1/29/2025: PEG tube planned today is cancelled based on SLP recommendation. SLP diet recommendation in place. Patient accepted into hospice On 1/30/2025: Patient discharged to in home hospice following SLP recommended diet.

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