Age: 53.0
Sex: M
Vaccine: COVID19
Symptoms: Bronchopleural fistula, COVID-19, COVID-19 pneumonia, Cardiac failure, Cardioversion
Clinical narrative: patient vaccinated 7/23/2021, admitted 7/29/2021, tested positive for covid 7/29/2021. discharged 8/14/2021, patient expired  Patient received Pfizer vaccine L deltoid lot numberFA6780 on 7/23/2021. Tested positive on 7/29/2021 after exposure. Writing  report since patient received vaccine and now critically ill and intubated to follow procedure. Patient intubated 8/7/2021  History Of Present Illness Patient is a 53-year-old patient with a PMH of CKD4 and HTN who presented to ED on 7/29 with complaints of fatigue, diarrhea, weakness, and loss of taste and smell.  Patient stated he was exposed to COVID on 7/20 and received his 1st COVID-19 vaccine on 7/23.  On presentation to the ED the Pt stated on 07/24 he began to have subjective fevers, weakness and fatigue, and the following day began having diarrhea and "passed out" 4 times since symptoms developed.  While on the floor the patient had been treated with dexamethasone 6 mg daily, remdesivir, and tocilizumab, and had been improving, weaned from HFNC to 4L NC on 8/5.  On 8/6 the patient had worsening shortness of breath and was transition back to high-flow nasal cannula.  Today, 8/7, the patient had worsening respiratory distress and increasing oxygen requirements 100% & 70L HFNC as well as 100% non-rebreather with persistent hypoxia.  MICU was called and the patient was emergently intubated for acute hypoxic respiratory failure.     Past Medical History He has a past medical history of CKD (chronic kidney disease), stage IV (CMS/HCC), Gout, and Hypertension.  Assessment and Plan:  The patient is a 53 yo M with CKD4,HTN that presents to UKMC on 7/29 and was diagnosed with COVID at this time. Progressive hypoxic RF that required HFNC, and on 8/7/21 required intubation with mechanical ventilation. Hospital course complicated by pneumomediastinum, transaminitis, and AKI secondary to COVID.    ARDS  COVID-19 PNA (POA) Pneumomediastinum, worsening  -XR chest with B/L peripheral and bibasilar opacities  -Inflammatory markers were up trending, will continue to monitor -CXR 8/6: showed air around heart borders and into mediastinum suggestive of pneumomediastinum -8/6: CT chest: significant pneumomediastinum, multifocal pulmonary infiltrates likely 2/2 COVID-19 pneumonia, official read pending -Thoracic surgery consulted: no interventions at this time unless the patient was to clinically decline. -S/p 5-day course of remdesivir finished on 8/6 -ID consulted, tocilizumab 800 mg one dose given 8/2/21 - PF ratio at time of transfer to the unit: 124 PLAN:  - Evaluate to repeat CT chest with patient clinical decline.  - Low PEEP ventilation with CT imaging indicating likely BPF at the area of the lingula.  - Minimize coughing and desynchrony while on mechanical ventilation: Propofol and Dilaudid gtts.  - ABG -Continue dexamethasone 6 mg daily (D6/10) -Albuterol inhaler Q 4 hrs. -Heparin 7500 U q8hrs for DVT ppx    AKI on CKD stage V not on Dialysis (POA) Hyperkalemia (POA) Mixed AGMA and NAGMA (POA) -Unknown baseline Cr, close to 6.8 upon admission with peak at 7.5, now stable/improving - Multifactorial acidosis: BUN, diarrheal illness, and  -K stable with lokelma as recommended per renal -Follows up with his nephrologist OP and was supposed to be referred for kidney transplant PLAN:  -Nephrology following on floor, will notify of transfer to the ICU - Place Udall-- > IHD to start 8/7.  -Continue sodium bicarb 1300 TID, calcitriol and vitamin D2 at same doses -Strict I&O, Daily weights - Foley    Seizure-like activity - Patient with right-sided upper extremity and lower-extremity tonic activity following intubation.  - Prior to intubation, patient had EMV 15, appropriate and no focal deficits.  - Likely metabolic in nature, patient with BUN >100, sepsis, COVID  - No past history of seizures.  PLAN:  - TSH, B12, ammonia - EEG   Newly diagnosed HFrEF (POA) -TTE with 40-50% EF and global LV hypokinesis PLAN:  -STOP coreg , HOLD home amlodipine  -OP follow up with cardiology for further workup given COVID  positive status   Transaminitis (POA) - Possibly multifactorial 2/2 volume depletion but also possible drug effect from remdesivir PLAN:  - CMP today and as needed.    Suspected orthostatic syncope related to COVID-19 infection -Started prior to admission in the setting of ongoing diarrhea, nausea and poor PO intake -No episodes since, symptoms improved with adequate fluid resuscitation -EKG on admission with sinus tachycardia with no significant ST-T changes -PT/OT, recs home with assistance  Obesity (POA) - BMI 35.8, complicates all aspects of care.   Hospitalization Admit Date/Time: 7/29/2021 3:55 PM Admitting Attending:  Discharge Date: 08/14/21 Discharge Attending Physician:    8/9/2021 Assessment and Plan   The patient is a 53 yo M with CKD4, HTN that presents to UKMC on 7/29 and was diagnosed with COVID at this time. Progressive hypoxic RF that required HFNC, and on 8/7/21 required intubation with mechanical ventilation. Hospital course complicated by pneumomediastinum, transaminitis, and AKI secondary to COVID.    Acute Respiratory Failure Requiring Mechanical Ventilation  Moderate ARDS  COVID-19 PNA (POA) Pneumomediastinum, stable Pneumopericardium, stable  HAP  -XR chest with B/L peripheral and bibasilar opacities  -CXR 8/6: showed air around heart borders and into mediastinum suggestive of pneumomediastinum -8/6: CT chest: significant pneumomediastinum, multifocal pulmonary infiltrates likely 2/2 COVID-19 pneumonia -Thoracic surgery consulted: no interventions at this time unless the patient was to clinically decline. -S/p 5-day course of remdesivir finished on 8/6 -ID consulted, tocilizumab 800 mg one dose given 8/2/21 - PF ratio at time of transfer to the unit: 127 - Started NMB on 8/8  PLAN:  - Low PEEP ventilation with CT imaging indicating likely BPF at the area of the lingula.  - Minimize coughing and desynchrony while on mechanical ventilation: Propofol and Dilaudid gtts.  - DC nimbex today, PF ratio increased to 164 after paralytic  -Continue dexamethasone 6 mg daily (stop date 8/11)  -Albuterol inhaler Q 4 hrs. -Heparin 7500 U q8hrs for DVT ppx  -Empiric Cefepime for HAP--Follow up cultures from 8/7 - DC vanc    AKI on CKD stage V(POA) Hyperkalemia (POA)--resolving Mixed AGMA and NAGMA (POA) -Unknown baseline Cr, close to 6.8 upon admission with peak at 7.5, now stable/improving - Multifactorial acidosis: BUN, diarrheal illness, and  -K stable with lokelma as recommended per renal -Follows up with his nephrologist OP and was supposed to be referred for kidney transplant -8/7: udall, failed IHD and converted to CRRT. PLAN:  - Nephrology following, appreciate recs  - Continue CRRT with goal net even  - Dose meds for CRRT  -Strict I&O, Daily weights   Shock, multifactorial  - Medication and sepsis related, stress induced CM - Received approx. 2 L IVF  - Cortisol 9.7 on 8/7 PLAN:  - Levophed for MAP >65 - Treatment of infections  - Defer stress steroids while on Dex, can evaluate to start stress HC Once steroids complete for Dex-ARDS.    Newly diagnosed HFrEF (POA) -TTE with 40-50% EF and global LV hypokinesis PLAN:   -OP follow up with cardiology for further workup given COVID  positive status   Transaminitis (POA) - Possibly multifactorial 2/2 volume depletion but also possible drug effect from remdesivir PLAN:  - CMP improving, weekly checks.    DM type 2 (POA) - Diet controlled at home.  PLAN:  - Start insulin gtt today, monitoring per protocol.    Hypertension - Hold Home meds until clinically appropriate.    Obesity (POA)- BMI 35.8, complicates all aspects of care  discharge note Chief Concern, Brief History of Present Illness, and Hospital Course Patient is a 53-year-old patient with a PMH of CKD4 and HTN who presented to UK ED on 7/29 with complaints of fatigue, diarrhea, weakness, and loss of taste and smell.  Patient stated he was exposed to COVID on 7/20 and received his 1st COVID-19 vaccine on 7/23.  On presentation to the ED the Pt stated on 07/24 he began to have subjective fevers, weakness and fatigue, and with reported syncopal events. Patient was treated with dexamethasone 6 mg daily, remdesivir, and tocilizumab.     On 8/6 the patient had worsening shortness of breath with increasing oxygen requirements.  On 8/7, the patient had worsening respiratory distress and increasing oxygen requirements 100% & 70L HFNC as well as 100% non-rebreather with persistent hypoxia ultimately requiring intubation. Furthermore, a dialysis catheter was placed and CRRT was initiated. Broad spectrum ABX were continued. On 8/8, he required addition of NMB for continued ventilator dys-synchrony. He completed the dex-ARDS protocol on 8/10. The patient had a decline on 8/11 with a fever, worsening shock. He was started back on broad spectrum antibiotics, vasopressin in addition to levophed, and stress dose steroids. Unfortunately, Pt remained with persistent and profound hemodynamic instability. His response to aggressive live saving measures was minimal. WBC up to 80 with no infectious source able to be identified, escalation of ABX still continued. CT scans unable to be obtained secondary to risk of fatal event occurring if moved and/or transported to scanner. On 8/13, Pt going into arrythmias which further exacerbated further instability, required cardioversions X 3 and antiarrhythmic medications. Goals of care discussions completed with wife. Despite attempting to give Pt more time to possibly respond to treatments, his status remained critical. Wife came to see her husband at bedside to be with him briefly before he passed away. Pt passed away on 8/14 at 8:11.