Age: 70.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Hyponatraemia, Iritis, Joint fluid drainage, Joint injury, Joint swelling
Clinical narrative: Hospitalized (9.2.21);  Deceased (9.17.21);  COVID-19 positive;  Fully Vaccinated Discharge Provider Primary Care Physician at Discharge Admission Date: 9/2/2021 Date of Death: 9/17/21 Time of Death:  3:30 PM Preliminary Cause of Death: Bacteremia       Discharge Disposition:  death   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hyponatremia Loss of vision AKI (acute kidney injury)   HOSPITAL COURSE: Patient is a 70 y.o. male with a pertinent past medical history for chronic diastolic heart failure, cirrhosis, non-insulin-dependent type 2 diabetes, who presented to the ED primarily with generalized weakness and left vision sided loss.  The patient's wife is at bedside and provides aspects of history.  8/19 he started having some confusion and generalized weakness and went to the ED due to wife concern for hepatic encephalopathy, however ammonia normal. He went back to the ED 8/25 and was found to be COVID positive but did not have any symptoms, he received monoclonal antibodies the next day. He presented to the ED again 8/31 for right knee pain and swelling and thought that he may have twisted his knee, he has had a prior arthroplasty there. Radiograph was negative for fracture or other acute abnormality at that time. He then returned with left eye vision loss that started 5-6 days prior to admission that he had never mentioned until day of admission. He was noted to have hyponatremia and mild AKI both of which corrected while hospitalized. CT orbits negative for globe issue. Ophthalmology evaluated him and stated this was Iritis and started patient on prednisolone and atropine drops (the atropine caused left eye pupillary dilation). He was evaluated by ortho and had his right knee tapped which returned septic and grew MSSA.  On Ancef with plan to continue 6 weeks course.   His hospitalization was complicated by his lethargy and confusion likely related to pain medications and liver function. He had a stroke rap called which did not show concern for a stroke. He was found to have MSSA bacteremia as well and was seen by ID. TTE negative for vegetations.  Unfortunately patient developed worsening LFTs and bilirubin.  Gastroenterology was consulted.  It is noted that patient had cirrhosis have baseline etiology unclear.  Hepatitis-C and hepatitis-B workup were negative.  Imaging did not show thrombus.  Acute liver failure was initially attributed to recent anesthesia exposure and Ancef use as well as Tylenol.  These medications were discontinued but LFTs continue to trend up.  There was also concern for Bilateral endogenous endophthalmitis.  IV Ancef was discontinued and patient was started on IV vancomycin and linezolid.  Unfortunately this led to acute kidney injury with high vancomycin trough level.  Given that his LFTs have continued to worsen despite stopping ancef, id felt the Ancef is less likely to be the cause of Abnormal LFTs, hence; he was placed back on Ancef and Vanco was discontinued.  Unfortunately patient continued to decline and have further elevation in bilirubin levels.  Ultimately after consultation with various consultants it was felt that the liver failure was more attributable to sepsis.  Renal function also continued to decline with subsequent noted hyperkalemia.  Given patient's overall decline and lack of options for possible medical intervention to reverse liver failure (patient deemed not to be a transplant candidate per Gastroenterology in setting of bacteremia) patient and family ultimately decided to pursue comfort care and patient was transitioned to inpatient comfort care on 09/16.  Palliative Care was consulted and assisted with medication.  Patient was placed on a fentanyl drip.  Physician was called that patient passed away at 3:30 p.m. 09/17/2021.  Patient officially pronounced on 15:50 on 09/17/2021.  Family present in room.