Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Bilevel positive airway pressure, Blood gases abnormal, COVID-19, Carbon dioxide decreased, Cardio-respiratory arrest
Clinical narrative: Patient hospitalized;  positive for COVID-19 (after vaccinated);  patient expired / died in hospital. DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Cellulitis of left leg [L03.116] Cellulitis [L03.90] Cellulitis of left lower extremity [L03.116] HOSPITAL COURSE: Patient is a 66-year-old female with past medical history significant for multiple medical comorbidities including severe peripheral arterial disease, chronic obstructive pulmonary disease, pulmonary hypertension, history of TAVR, history of TIA, morbid obesity, OSA/CPAP, diabetes on insulin, CKD 3B, chronic diastolic heart failure, peripheral edema, chronic pain, ongoing tobacco abuse recent fall resulting in a right fibular fracture presents to hospital on 08/23 from subacute rehab facility due to worsening lower extremity pain, lethargy, chills, decreased oral intake for about 5 days prior to presentation and was incidentally noted to be COVID positive.  Patient also recently had a hospital stay from 07/28 to 8/3 due to a right fibular fracture and was fitted with a cam boot with instructions to weight bear as tolerated.  Patient was admitted with working diagnosis of acute encephalopathy and lower extremity cellulitis on the left and asymptomatic COVID-19 infection. Encephalopathy:  Felt to be related to polypharmacy including sedating medications namely gabapentin, Norco and possibly also related to infection.  VBG with CO2 of only 44. With supportive treatment alone, her encephalopathy improved over the next 24-48 hours and resolved completely.  Only Norco was restarted.  Gabapentin was planned to be discontinued due to ineffectiveness. Cellulitis:  Patient was noted to have left leg cellulitis associated with changes consistent with venous stasis and edema.  Patient was started on Ancef initially but surface cultures obtained at the time of admit showed MRSA and hence vancomycin was added on top.  Ancef was discontinued on 08/24 with plans to continue vancomycin and eventually switch over to doxycycline to completed 10 day course.  Cellulitis gradually was improving; COVID-19 infection:  Incidentally noted at rehab on 08/22,  patient without much respiratory symptoms and continued on 3 L baseline oxygen and hence no particular treatment was initiated. Right fibular fracture: due to previous fall/recent hospital stay at which time orthopedics recommended non operative management with a Cam boot and weight-bearing as tolerated.  Patient had not had a chance to follow-up with orthopedics and hence consult was obtained here.  Repeat x-ray showed improvement and possible healing, Orthopedics recommended continuation of Cam boot with weight-bearing as tolerated in outpatient follow-up. Peripheral arterial disease:  With extensive nature of peripheral arterial disease noted on previous imaging studies with plans for following up with vascular surgery at Metro Hospital with upcoming plans for angiography/angioplasty.  There was no concern for acute ischemia on exam. Anasarca, acute on chronic diastolic congestive heart failure with significant weight gain compared to previous hospital stay.  Daughter did mention that subacute rehab did not really pay close attention to her salt intake and weight gain and she had gained significant amount await (close to 20 kilos) and hence aggressive IV  Lasix/diureses were started.  Her renal function mostly was holding in spite of aggressive diureses and slow weight loss.  This was also noted in the lower extremities with improvement in the edema. On 08/28,  during my interview patient had a unremarkable night, used her BiPAP in the night, noticed that she was slightly more short of breath ( while she had taken off her CPAP mask, had not put her oxygen on yet), a short while later when she was helped to the bedside commode for urination, patient became acutely short of breath, appeared  unwell and lost her pulse is.  All code was called and resuscitation efforts were continued for 29 minutes and and unsuccessful in obtaining ROSC, pronounced at 11:35 a.m..  Suspicion was that she may have had a PE or seizure (she did have seizures during resuscitation). Daughter was notified, discussed with a little bit later when she arrived at bedside. Not a ME case, daughter did not want autopsy; Death certificate signed.