Age: 49.0
Sex: M
Vaccine: COVID19
Symptoms: Abdominal distension, Acute kidney injury, Acute respiratory failure, Anticoagulant therapy, Atrial fibrillation
Clinical narrative: Deceased (2.20.22); Hospitalized (1.13.22 at hospital for 36 days / transferred to privacy on 2/18/22-2/20/22); COVID-19 positive (1.5.22); Fully vaccinated - unknown # of doses as pt has >4 doses documented. HOSPITAL Discharged as Deceased Summary   BRIEF OVERVIEW: Discharge Provider: (privacy) Primary Care Physician at Discharge: (privacy) Admission Date: 2/18/2022   Active Hospital Problems   Diagnosis Date Noted POA ? Acute respiratory failure  02/18/2022 Unknown ? COVID-19 02/18/2022 Unknown ? AKI (acute kidney injury)  02/18/2022 Unknown ? DVT of lower limb, acute  02/18/2022 Unknown ? PAF (paroxysmal atrial fibrillation) 02/18/2022 Unknown Date of Death: 2/20/22 Time of Death:  1:24 AM Preliminary Cause of Death: Acute respiratory failure due to COVID-19    Discharge Disposition: Deceased   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute respiratory failure    HOSPITAL COURSE: Patient is a 49 year old with history of ESRD secondary to interstitial nephritis (h/o LUE AV fistula).  He had renal transplant from his father 1/'03 with eventual allograft failure.  First transplant was complicated by histoplasmosis in '07.  He received a second renal transplant 1/'19 with persistent CKD3.  Second transplant was complicated by ganciclovir-resistant CMV infection as well as PE (1/'19).  He also has a history of pAfib (OP Coumadin), HFrEF, HTN, obesity.  He tested (+) for COVID-19 1/5 (fully vaccinated).  He received mAb 1/7 and was admitted to hospital 1/13 with hypoxemia.  He received Tocilizumab 1/15 and started on steriods.  On 1/24, he was noted to have a RLE peroneal DVT (while on Coumadin) and was transitioned to Eliquis.  He developed escalating oxygen needs, up to intermittent BiPAP / HFNC 1/25.  He was started on increased steroids and was empiric Cefepime / Vori.  CT 2/5 showed an increase in GGO and bronchiectasis.  Bronchoscopy was done 2/7 with cultures (+) for CMV for which Foscarnet was started 2/11.  He had already showed improvement as was weaned to 4L NC by 2/11.  He, however, again developed increased oxygen needs and again was briefly placed on BiPAP 2/13 followed by increasing HFNC requirement.  He was diuresed and treated with 3 days pulse Solumedrol 2/13-2/15.  Followup CT 2/16 showed increased bilateral ASD.  Empiric Zosyn and IV Vanco were added 2/16.  Reportedly 1:2 blood cultures were (+) in anaerobic bottle.  On 2/17, he required intubation for type 2 respiratory failure - requiring 70% FiO2.  He was transferred to hospital 2/18 for lung transplant evaluation.  Despite aggressive measures, he has been persistently hypercapnic with worsening ABGs. After multiple discussion with his family and the progressive decline, the decision to pursue comfort care was made. His paralytic was stopped and he started to initiate his own breaths. His family remained at his bedside. Before he was extubated and pressors stopped his BP dropped significantly to 44/20. He was extubated and was found without spontaneous pulses or respiraiotns at 0124. His pupils were fixed and dilated. He was pronounced deceased at that time. Dr. was notified and will sign the death certificate  2/18/22 Med Critical Care H&P:  CHIEF COMPLAINT: Acute respiratory failure  ASSESSMENT / PLAN:  49 y.o. male admitted to the ICU for COVID-19 pneumonia   Assessment and Plan PAF (paroxysmal atrial fibrillation)  Assessment & Plan PAF on coumadin at home Now on eliquis --given developing aki will transition to heparin gtt.    DVT of lower limb, acute  Assessment & Plan DVT -right peroneal DVT on 1/24 On eliquis   AKI (acute kidney injury)  Assessment & Plan AKI S/p renal transplant x2 most recently a Deceased donor in 2019 Baseline cr 1.3 Suspect over diuresis Hold lasix Consult nephrology Was on MMF and tacrolimus: while clarify infection status would prefer to hold MMF   COVID-19 Assessment & Plan Positive on 1/13 Hospitalized from 1/13-2/17 BAL with CMV, no bacteria or fungus on 2/15 Worsened and intubated on 2/16--at this stage active covid infection is still possible given his immunosuppressed status but organizing pneumonia, acquired and opportunistic infections are more likely the culprit   * Acute respiratory failure  Assessment & Plan Covid-19 pneumonia Admitted to hospital on 1/13 and transferred to another hospital on 2/17 with request to be evaluated for a lung transplant.  During course at hospital was treated with decadron, Tocilizumab, Monoclonal abs and the an extended solumedrol course.  He worsened acutely an required intubation on 2/16. Suspected HCAP, also BAL on 2/15 was positive for CMV and he was treated for CMV viremia and presumed CMV pneumonitis with foscarnet Most recently he started on Vancomycin and zosyn on 2/16 after being intubated.    Plan: On propofol only for sedation, will add fentanyl and target RASS -5 for brief paralytic period to measure lung compliance and get a CT chest to assess parenchymal disease pattern At this point it is not clear if he has hospital acquired bacterial pneumonia, CMV pneumonitis and post-acute sequelae of COVID-19 including organizing pneumonia which a CT may be helpful to assess.  Solumedrol: had been off steroids entirely since 2/15. Will decide on steroid regimen after CT chest.  Consult ID      Discussion Deepen sedation, get CT Notified by hospital that 1/2 blood cultures from 2/16 are positive for GPCs in pairs and clusters. Continue vancomycin and zosyn, MRSA swab x2 negative at hospital.  Reason for transfer was consideration of lung transplant evaluation however there is a lot of diagnostic uncertainty and likely acute infection present. Will get CT chest, rest of plan above.  Subjective    HISTORIES: HPI: 49 y.o. male 49 year old with history of ESRD secondary to interstitial nephritis.  He had renal transplant from his father 1/'03 with eventual allograft failure.  First transplant was complicated by histoplasmosis in '07.  He received a second renal transplant 1/'19 with persistent CKD3.  Second transplant was complicated by ganciclovir-resistant CMV infection as well as PE (1/'19).  He also has a history of pAfib (OP Coumadin), HFrEF, HTN, obesity.  He tested (+) for COVID-19 1/5 (fully vaccinated).  He received mAb 1/7 and was admitted to hospital 1/13 with hypoxemia.  He received Tocilizumab 1/15 and started on steriods.  On 1/24, he was noted to have a RLE peroneal DVT (while on Coumadin) and was transitioned to Eliquis.  He developed escalating oxygen needs, up to intermittent BiPAP / HFNC 1/25.  He was started on increased steroids and was empiric Cefepime / Vori.  CT 2/5 showed an increase in GGO and bronchiectasis.  Bronchoscopy was done 2/7 with cultures (+) for CMV for which Foscarnet was started 2/11.  He had already showed improvement as was weaned to 4L NC by 2/11.  He, however, again developed increased oxygen needs and again was briefly placed on BiPAP 2/13 followed by increasing HFNC requirement.  He was diuresed and treated with 3 days pulse Solumedrol 2/13-2/15.  Followup CT 2/16 showed increased bilateral ASD.  Empiric Zosyn and IV Vanco were added 2/16.  On 2/17, he required intubation for type 2 respiratory failure - requiring 70% FiO2.  He was transferred to hospital 2/18 for lung transplant evaluation  OBJECTIVE: Pulse 69  | Temp 37.4 °C  | Resp 27  | Ht 1.8 m  | Wt 88.7 kg  | SpO2 93%  | BMI 27.38 kg/m²  FIO2 (%): 70 %  Score                9.5    SOFA RESPIRATORY:   3.1   SOFA COAGULATION:   2.1   SOFA LIVER (BILIRUBIN):   0.1   SOFA CARDIOVASCULAR:   0.1   SOFA CENTRAL NERVOUS SYSTEM:   0   SOFA RENAL:   Physical Exam Constitutional:      Appearance: He is ill-appearing.  Pulmonary:     Breath sounds: Rales present.  Abdominal:     General: There is distension.     Tenderness: There is no abdominal tenderness.  Skin:    General: Skin is warm.