Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Hypotension, Hypoxia, Incontinence, Intensive care, Laboratory test normal
Clinical narrative: Discharge Provider: MD;* Primary Care Physician at Discharge: MD Admission Date: 1/22/2023   PRESENTING PROBLEM: Multifocal pneumonia [J18.9]   HOSPITAL COURSE: Patient is a 65 y.o. female with a history of mantle cell lymphoma, pulmonary emboli on Eliquis and GAD who presented with cough and shortness of breath. Patient stated she has not been feeling well since the beginning of the month. She stated she has fever, chills, cough, persistent diarrhea, decreased appetite and malaise. On 1/5/2023 she was diagnosed with COVID and treated with molnupiravir. She endorsed being incontinent due to perfuse diarrhea and had little oral intake. The diarrhea has resolved but she continues with a cough, increasing shortness of breath and fatigue. Her husband called 911 and EMS arrived. Patient was found to be hypoxic and placed on 4L 02 to maintain sats above 90%.   Upon arrival to the emergency department patient was found to be hypotensive and was given a 1 L bolus of IV fluids.  She was hypoxic and placed on 2 L of oxygen to maintain sats above 90%.  COVID PCR positive.  Lab work was relatively unremarkable.  Blood gas did demonstrate hypoxia.  Chest x-ray demonstrated extensive bilateral airspace opacities suspicious for multifocal pneumonia.  Blood cultures were drawn and she was given IV Rocephin, azithromycin and vancomycin.  She was admitted with hospitalist services for further care and treatment of COVID-19, multifocal pneumonia and hypoxia.   Patient was started on IV cefepime and vancomycin.  Patients diarrhea returned and then subsided without testing.  Blood cultures positive for Staph hominis.  Repeat blood cultures obtained.  ID consulted and suspected patient has bacterial super infection after COVID, ID recommendations were followed. She completed a 10 day course of antibiotics.   Her oxygen needs waxed and waned. She was diuresed with lasix. She had to be moved to ICU for hypotension and was given fluid boluses and intermittently levophed was used to maintain blood pressure. She slowly started to improve and oxygen demand was decreasing. Then February 3 and 4 her oxygen demand significantly increased requiring HFNC on the evening of 2/4. CTA indicated worsening Covid pneumonia and ruled out PE. Patient wishes were reviewed and she continued to be adamant about not wanting intubation.    VICU and ID were participating in care. She was again started on broad spectrum antibiotics. She had intermittent hypotension and maintaining peripheral access was difficult. A PICC line was placed, and supportive care with pressers continued. Due to worsening need for oxygen and hypotension goals of care were again discussed and Hospice was consulted for further assistance on February 6th. Patient and husband made plan to discharge home with hospice, but unfortunately after completion of plans and being left alone her oxygen needs increased and were being met by HFNC at 95% and a venti mask. She was made comfort measures on 2/6 in the evening and passed away at 7:03 on 2/7/23 with husband and granddaughter at bedside. Hospice was notified.