Age: 79.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Anticoagulation drug level above therapeutic, Aspartate aminotransferase normal, Asthenia, Basophil count, Blood albumin decreased
Clinical narrative: 1/22/22 80 yr/o male who presents to the Emergency Department complaining of vomiting blood.  Patient is unable to provide any history at this time as he has garbled speech and is combative.  Per report EMS was called for the patient either coughing or vomiting blood.  He noticed his oxygen levels were low in route.  His daughter arrived shortly after began my evaluation at the bedside.  She provides majority of the history.  She states that he was diagnosed with cancer of his gastroesophageal junction at the end of November.  He subsequently developed COVID which he was exposed at the end of December and was in the hospital at an outside facility until the 16th of this month with COVID-pneumonia. He was discharged home on 2 L of oxygen which the daughter states was adequate when he was awake and sitting upright but at night his oxygen would drop and she would have to turn it up to 4 to 5 L.  States over the past 2 days he has been complaining of feeling nauseous and not wanting to eat and feeling weak.  She states today he was able to take 2 of his morning medications but when attempting to take more he declined stating he did not feel like he could swallow.  She states shortly thereafter he began regurgitating a pink-colored fluid.  She did not note any cough when this was occurring and states it appeared to be "reflux".  This prompted her to call EMS.  He has had episodes of regurgitation in the past but has never been discolored.  She is not aware of any black or tarry stools.  She does note he did not take his Lasix this morning and she has noticed some intermittent swelling of his ankles.  She notes that she is the second designee for his medical power of attorney his wife being the first.  She is unsure if he has an advanced directive or living well.  She will attempt to obtain these or get a hold of the patient's wife so we can discuss his wishes. Physical Exam Constitutional:      Appearance: He is underweight. He is ill-appearing.  HENT:     Head:     Comments: There is bright red saliva present in the patient's mouth and face. Neck:     Thyroid: No thyroid mass.  Cardiovascular:     Rate and Rhythm: Normal rate. Rhythm irregular.     Pulses:          Radial pulses are 1+ on the right side and 1+ on the left side.  Pulmonary:     Comments: Mildly tachypneic, there is rhonchi at the right middle and lower lobes. Chest:     Chest wall: No deformity or crepitus.  Abdominal:     General: Abdomen is flat. Bowel sounds are decreased.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Neck supple.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is pale.  Neurological:     Mental Status: He is easily aroused. He is lethargic and confused.     GCS: GCS eye subscore is 3. GCS verbal subscore is 2. GCS motor subscore is 6.  Psychiatric:        Behavior: Behavior is uncooperative.   Hospital Problems:  Principal Problem:   Acute blood loss anemia (1/22/2022)   Active Problems:   Pneumonia of both lower lobes due to infectious organism    Hemoptysis      Discharge Diagnoses: Acute blood loss anemia, hemorrhagic shock, septic shock, sepsis due to aspiration pneumonia, acute respiratory failure with hypoxia, coagulopathy, acute renal failure likely due to ATN Hospital Course:  Patient was admitted with impression of acute blood loss anemia due to upper GI bleeding likely from known esophageal cancer exacerbated by anticoagulation on Coumadin with supratherapeutic INR.  INR was reversed with Kcentra and IV vitamin K, he received blood product and IV fluids.  He was treated for aspiration pneumonia with Zosyn and required intubation for hypoxia and airway protection.  Intensivist and GI service manage alongside, however patient's hemodynamic stability declined and he required up to 4 vasopressors.  His course was further complicated by AKI suspected to be due to ATN in setting of hypotension/anemia.  Patient's family opted to make patient comfort care.  Patient expired at 13:14.