Age: 70.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Epistaxis, Febrile neutropenia, Fibrin D dimer, Haematocrit normal, Haemoglobin normal
Clinical narrative: 1/14/2022- Presented to ER with complaints of constipation, weakness and feeling dizzy upon standing. Currently on Zarxio injections (chemotherapy). Covid test negative. Admit sepsis neutropenic fever. WBC-0.7, Zarxio injection ordered. CT head wo IV contrast-no evidence of acute infarct, Chest X ray- Diffuse bilateral emphysematous changes are noted. Coarse reticular interstitial disease present. Due to history of CAD, plavix and aspirin ordered. Lovenox ordered.  1/15/2022- Hypoxic requiring 1L of o2 via NC. WBC- decreased to 0.5 .Temp 100.1  1/16/2022- Temp 100.5, HR-98, BP-76/40 increased o2 need 2L via NC , o2 sat 98%. Procalcitonin -1.23 start on Unasyn and doxycycline. 250cc bolus completedx2    1/16/2022 -for lightheadeness  1/17/2022-BP-97/40, WBC 1.0 and CRP-27 AKI. Continue with IV Zosyn and continue doxycycline. D/C Unasyn. Continue Zarexio to increase WBC. 250ml bolus given for soft BP. Chest CT wo IV contrast- Improved aeration compared to prior exam, resolution of previously visualized pleural effusions, Posterior right upper lobe infiltrates and emphysema changes. Continues on 2L o2 via NC  98% o2 sat.  1/19/2022-WBC 13.5. D/C Zarexio. o2 sat 98% o2 1L via NC. IV Vanco and cefepime started + MRSA sputum culture.  1/21/2022- Epitaxis episode, H&H stable, Plavix, Lovenox and aspirin held. WBC increased to 17.5. Change in mental status, Head Ct- no acute intracranial abnormality.  1/22/2022- Cefepime changed to Ceftriaxone. Decreased appetite and increased confusion. AMS with hallucination MRI Brain ordered. Oncology d/c any further chemotherapy due to comorbidities.  1/24/2022- O2 increased to 3L via NC o2 sat 91%.  1/25/2022- O2 increased to 4.5 L via NC o2 sat 83-89%. Lasix ordered worsening hypoxic respiratory failure.  1/26/2022- MRI Brain - no evidence of acute intracranial abnormality. More alert.  1/27/2022- O2 decreased to 2.5L NC after patient extracted large nasal mucus plug. ENT Consult nasal lavage ordered. 1/29/2022- O2 increased to 4.5L after o2 sat was 87%, 90% after o2 increase.  1/31/2022- Covid + test.  2/1/2022- O2 increase to 5L via NC o2 sat 90%.  Dx- Covid pneumonia and acute hypoxic respiratory failure. Chest CT- no evidence of PE.  Continue ceftriaxone and vancomycin and add  remdesivir and decadron.  2/3/2022- D/C Po Lasix start IV lasix.  On 6L o2 NC sat 90% 2/5/2022- Currently, on 3L o2 NC sat 88%. Intermittent epistaxis, hold Lovenox, Plavix and aspirin.  2/8/2022- Remains on IV Vanco and IV Rocephin. Satting 87-96% on 1.5-2L of o2 NC. D/C Planning for SNF. 2/9/2022- 3L o2 NC o2 sat 93% , D-Dimer-2,925  CT chest ordered to r/o PE, D/C IV Vancomycin and ceftriazone, start Linezolid and Solu-Medrol. Continue Decadron.  2/12/2022- Episode of desaturation to 82% , non-rebreather applied. RT saw patient, patient requested NC to be reapplied, sat now 91%. 2/13/2022- O2 5l via NC sat around 88-91%. 2/16/2022- WBC-16. Medically ready for discharge.3L o2 via NC sat 92-99%. Continue Linezolid.  Repeat Covid + test.  2/17/2022- 3-4L o2 via NC sat 88%, another episode of epistaxis d/c aspirin and continue Plavix and Lovenox. 2/19/2022- Productive cough with tan colored secretions. Nasal lavage passing of large blood clots from nose. Family discussion agreeable to DNR/DNI with no BiPap. chest x ray-Increasing bilateral consolidative infiltrates. Started on cefepime continue Linezolid.  2/20/2022- Placed on venti mask 8L/min o2 sat 95%.   2/21/2022- DNR/DNI remains, family meeting to make palliative. D/C aspirin, Lovenox and Plavix due to epistaxis.  2/22/2022- Labored breathing, continue Venti Mask 8L/min sat  94-95% Comfort medications ordered : Roxanol and lorazepam.  2/23/2022- Started on Morphine gtt. Increased anxiety, ordered for one time dose of IV Ativan and IV Morphine. Increased pain noted, PCA Added. 2/24/20220- Unresponsive due to morphine gtt, PCA drip rate increased for air hunger. Patient expired @ 0110.