Encephalopathy unspecified Late effect of intracranial injury without mention of skull fracture Late effects of unspecified accident Epilepsy unspecified without mention of intractable epilepsy Alcohol abuse unspecified Thrombocytopenia unspecified Anemia unspecified Memory loss Tobacco use disorder Mild cognitive impairment so stated Toxic encephalopathy Acute alcoholic hepatitis
 
Name:  ___             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Allergies/ADRs on File
 
Attending: ___.
 
Chief Complaint:
Encephalopathy
Traumatic Injury

 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
Unable to obtain history from patient. Predominantly obtained 
from ___ at ___ Facility and sister 
___ .
.
This is a ___ male with history of EtOH abuse, seizure 
disorder, and and serious traumatic brain injury with memory 
deficit who presents after being found altered at the ___.  
.  
Per ___ (who found the patient) the patient is 
normally communicative at baseline. On the eve of ___ 
however, the patient was not answering the door in his room. The 
visiting nurse came came in and found the patient altered and 
vomiting. There was a heavy odor of EtOH in the room. The nurse 
took the vitals which were okay. They assumed the patient was 
drunk and left the patient alone. A few hours later the patient 
was checked on and was seemingly more altered. At that point 
bruises were noted on the patients back and sides. He vomited 
again. EMS was called and the patient was brought to ___.  
.  
Upon presentation to the emergency department, initial vitals 
were: T 99.2, HR 76, BP 136/78, RR 16, SaO2 97% 4L NC. Given 
inability to give history, a trauma scan was done with CT head, 
neck and torso. The CT head or spine prelim no acute process. 
CTA chest and CTAP showed no pulmonary embolism, a foci of 
tree-in ___ in the LLL could be aspiration and fatty liver. CXR 
with fractures but otherwise clear. He was observed to have 
marks over lower extremeties. He only answered "yes" to all 
questions. Urine and blood toxicity were negative. Labs returned 
with a lactate of 3.1, WBC 7.1. UA negative. He became hypoxic 
to ___ and required NRB. Weaned to 2L NC and saturating well 
with oxygen on. On room-air drops to ___. He was given 4L IVF, 
vancomycin, ceftriaxone and metronidazole for aspiration 
pneumonia. LP was done and is thus far unrevealing. He was 
admitted to medicine for further evaluation and management of 
altered mental status.
 
Past Medical History:
1. EtOH abuse  
2. Seizure disorder  
3. h/o traumatic brain injury requiring multiple craiectomies in 
___ - with memory deficit 
4. Subdural hematoma - ___

 
Social History:
___
Family History:
He has a sister who lives in ___ who is well. 
Otherwise, no family history obtainable from the patient due to 
memory deficits.
 
Physical Exam:
On Admission:
VS: T 100.8, BP 142/82, HR 66, RR 20, SaO2 98% RA  
GENERAL: well-appearing, no apparent distress, lying in bed, not 
answering questions.  
HEENT: NC/AT, PERRL, sclerae anicteric, would not open mouth  
NECK: supple  
LUNGS: Limited exam. Not cooperating with exam. No clear 
crackles or wheezes although very small breaths.  
HEART: RR, nl rate, limited due to positioning. No murmur 
appreciated  
ABDOMEN: soft, NT/ND, BS, no rebound or guarding  
EXTREMITIES: WWP, no edema, 2+ peripheral pulses  
SKIN: multiple bruises on back and arms. Skin marking ___ - 
unclear lesion  
NEURO: awake, A&Ox0 - not answering question, unable to complete 
exam as patient not participating  

On Discharge:
V: Tm 100.2  Tc 99.0 BP 120-134/62-84s HR ___ RR 18 O2 99RA
PE:
GENERAL: Adentulous, multiple abrasions over back and LEs, 
bruise and abrasion under right eye, though no apparent 
distress, Sitting in chair laughing at TV, making attempts to 
answer questions with confabulation.  
HEENT: Abrasion as above, PERRL, sclerae anicteric, adentulous, 
MMM  
NECK: supple  
LUNGS: Diffuse wheezes, good movement of air.  
HEART: RRR, nml s1s2, no m/r/g.  
ABDOMEN: Multiple scars on abdomen, prominent scar on RLQ, soft, 
NT/ND, +BS, no rebound or guarding  
EXTREMITIES: WWP, no edema, 2+ peripheral pulses  
SKIN: multiple bruises on back, arms, and legs. 
NEURO: awake, A&Ox1 - attempting to answer questions, CN II-XII 
intact.

 
Pertinent Results:
On Admission:
___ 07:00PM BLOOD WBC-7.1 RBC-4.14* Hgb-13.1* Hct-38.9* 
MCV-94 MCH-31.6 MCHC-33.6 RDW-13.4 Plt ___
___ 07:00PM BLOOD Neuts-89.2* Lymphs-7.9* Monos-2.3 Eos-0.1 
Baso-0.5
___ 07:00PM BLOOD ___ PTT-22.6 ___
___ 07:00PM BLOOD Glucose-126* UreaN-9 Creat-0.7 Na-145 
K-4.2 Cl-105 HCO3-25 AnGap-19
___ 06:50AM BLOOD ALT-203* AST-149* LD(LDH)-235 
CK(CPK)-632* AlkPhos-41 TotBili-0.8
___ 06:50AM BLOOD Albumin-4.2 Calcium-8.7 Phos-3.0 Mg-1.7
___ 07:14PM BLOOD Glucose-122* Lactate-3.1* K-4.1

___ 06:30AM BLOOD WBC-4.9 RBC-4.01* Hgb-12.8* Hct-37.3* 
MCV-93 MCH-32.0 MCHC-34.3 RDW-13.3 Plt ___
___ 06:50AM BLOOD Neuts-76.8* Lymphs-17.0* Monos-5.9 
Eos-0.1 Baso-0.2
___ 06:30AM BLOOD Glucose-122* UreaN-13 Creat-0.7 Na-138 
K-3.2* Cl-98 HCO3-28 AnGap-15
___ 06:30AM BLOOD ALT-191* AST-124* LD(LDH)-267* AlkPhos-43 
TotBili-1.2
___ 06:30AM BLOOD Calcium-9.5 Phos-2.9 Mg-1.9
___ 06:50AM BLOOD Lipase-27
___ 06:50AM BLOOD CK-MB-3 cTropnT-<0.___ male with history of EtOH abuse, seizure disorder 
and history of traumatic brain injury with memory deficit who 
presented after being found altered at his facility.

Altered mental status:  Exact etiology unclear. At baseline 
patient has limited capacity due to prior traumatic brain injury 
and has a long history of EtOH abuse. Since patient was found 
vomiting at home concerning for infection, however cultures, 
Head and CT torso, as well as LP all negative. Chest CT was 
suggestive of aspiration and patient was empirically started on 
vancomycin, ceftriaxone, and metronidizole, however this was 
stopped upon admission as patient did not appear to have a 
pneumonia clinically. Given patient's seizure history, EEG was 
performed which was negative for seizure activity. No metabolic 
or endocrine causes found. Through admission, patient's mental 
status cleared. Per his sister, he was at his baseline. It was 
thought patient may have had a seizure in his residence with a 
prolonged post-ictal period. The true etiology could not be 
determined. He has close follow up appointments with his PCP and 
neurologist at ___.  

# Seizure disorder: Continued home Keppra. EEG performed was 
negative for seizure activity.

# EtOH abuse: EtOH level was negative. Patient does have 
significant ethanol history. He was placed on thiamine, folate 
and MVI.

# Thrombocytopenia: Remained stable during admission.

# Anemia: Remained stable during admission.

 
Medications on Admission:
Keppra 1000 BID
 
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 
times a day).
Disp:*120 Tablet(s)* Refills:*2*

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary:
Encephalopathy NOS
Hepatitis NOS

Secondary:
Traumatic brain injury
Cognitive and memory impairment
Alcohol abuse
Seizure disorder

 
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Mr. ___,

It was a pleasure caring for you at the ___ from ___ to 
___. You were admitted for confusion and vomiting on the 
evening of ___. You had a very extensive work up that was 
unrevealing. Everything was negative, and notably your EEG 
(seizure test) was negative. Over the course of 24 hours your 
mental status improved to your baseline. Though it is unclear 
exactly what caused you encephalopathy it improved.

We have made appointments with your primary care phycian and 
your neurologist. We strongly recommend you keep these 
appointments to insure you continue to improve.

You should continue to take your medications as prescribed 
 
Followup Instructions:
___

{'Encephalopathy': ['Encephalopathy', 'Late effect of intracranial injury without mention of skull fracture', 'Epilepsy', 'Alcohol abuse', 'Thrombocytopenia', 'Anemia', 'Memory loss', 'Tobacco use disorder', 'Mild cognitive impairment', 'Toxic encephalopathy', 'Acute alcoholic hepatitis'], 'Late effect of intracranial injury without mention of skull fracture': ['Encephalopathy', 'Late effect of intracranial injury without mention of skull fracture'], 'Epilepsy': ['Encephalopathy', 'Epilepsy'], 'Alcohol abuse': ['Encephalopathy', 'Alcohol abuse'], 'Thrombocytopenia': ['Encephalopathy', 'Thrombocytopenia'], 'Anemia': ['Encephalopathy', 'Anemia'], 'Memory loss': ['Encephalopathy', 'Memory loss'], 'Tobacco use disorder': ['Encephalopathy', 'Tobacco use disorder'], 'Mild cognitive impairment': ['Encephalopathy', 'Mild cognitive impairment'], 'Toxic encephalopathy': ['Encephalopathy', 'Toxic encephalopathy'], 'Acute alcoholic hepatitis': ['Encephalopathy', 'Acute alcoholic hepatitis']}