Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: Pleural effusion, Pneumocystis jirovecii pneumonia, Procalcitonin, Protein total decreased, Rales
Clinical narrative: Hospitalized (4.14.22 - 4.19.22); COVID-19 positive (4.14.22); fully vaccinated PLUS Booster - moderna x3.  D/c with hospice - deceased on 4/25/2022 D/c summary:Discharge Summary Physician General Medicine  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 4/14/2022 Discharge Date: Apr 19, 2022  Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 Pneumonia 04/15/2022 Yes ? Goals of care, counseling/discussion 04/15/2022 Unknown ? Dry mouth 04/15/2022 Unknown ? Protein-calorie malnutrition, moderate 04/15/2022 Unknown ? Multiple myeloma  Yes ? hx of Pneumocystis jirovecii Pneumonia Feb 2022   Yes ? FTT (failure to thrive) in adult 04/06/2022 Yes ? Acute hypoxemic respiratory failure 02/17/2022 Yes ? hx of respiratory failure due to COVID-19 Feb 2022 02/04/2022 Yes ? Cardiac amyloidosis, transthyretin by endomyocardial biopsy 01/10/2022 Yes ? Cardiac amyloidosis with resultant acute on chronic diastolic heart failure 12/09/2021 Yes ? Chronic bilateral pleural effusions 11/18/2021 Yes ? Cardiac pacemaker in situ 08/11/2021 Yes ? Chronotropic incompetence 06/24/2020 Yes ? Atrial fibrillation, persistent 04/21/2020 Yes ? hx of primary adenocarcinoma of lower lobe of right lung s/p wedge resection   Discharge Disposition:  hospice/home  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute hypoxemic respiratory failure due to COVID-19 COVID-19   HOSPITAL COURSE: 84-year-old male with a PMH of atrial fibrillation on Eliquis, chronotropic incompetence, pacemaker, combined CHF with EF 43%, multiple myeloma, hx of lung cancer s/p bilateral resection, immunocompromised on acyclovir, hx of bilateral pleural effusions, and a recent medical hx of pleural effusions s/p thoracentesis with Interventional pulmonology 4 months ago, COVID pneumonia 2 months ago, PJP pneumonia 1.5 months ago, and hospitalization for failure to thrive 4 days ago who presented with a CC of hypoxia x1 day.  CTA thorax negative for PE, positive for moderate pleural effusions, extensive parenchymal lung opacities suggestive of mixed resolving pneumonia and suspected new organized pneumonia, evidence of prior LLL lobectomy and RLL wedge resection, redemonstrated cardiomegaly with dual lead pacemaker in place, evidence of elevated right heart pressures and unchanged dilation of the aortic root.  Limited film array positive for COVID, procal 0.48 nomral WBC on admission 9.3, legionella/strep pneumo negative patient started on Rocephin and doxycycline and admitted for further care.   Pulmonology consulted and patient underwent left-sided thoracentesis on 04/15 was 850 mL removed.  Unfortunately this was very uncomfortable for patient in did not seem to significantly improve his dyspnea.  Pulmonology did feel that pneumocystis and COVID likely were not current active issues.  COVID isolation was discontinued.  They did feel that the patient's pulmonary symptoms were likely largely secondary to congestive heart failure.  Cardiology also consulted who recommended diuresis.  Both pulmonology and Cardiology did state patient had poor prognosis and the importance of goals of care discussion.  Palliative care consulted.  Subsequently hospice consulted.  Decision was made on 04/16 to pursue comfort care hospice.  Unfortunately hospice was unable to arrange intake in the home until 4/19.  In the interim patient was continued on IV Lasix and antibiotics.  Started on morphine sublingual p.r.n..  On discharge all medications will be discontinued with the exception of medications required for comfort.  Prescription for sublingual morphine and Ativan have been sent to the pharmacy and will be obtained and ready for patient via the hospice nurse.  Due to shift change (4/19 new physicin coming on service) discharge orders ready but will ask hospitalist in am to check patient to ensure stable before transfer.  CONSULTS / RECOMMENDATION: Consult Orders (From admission, onward) IP CONSULT TO PALLIATIVE CARE      Provider: Palliative Care IP CONSULT TO PULMONOLOGY      Provider:  MD  IP CONSULT TO CARDIOLOGY      Provider: MD IP CONSULT TO INFECTIOUS DISEASES      Provider: Infectious Disease INPATIENT PROCEDURES: Thoracentesis 4/15   BP 121/65  | Pulse 89  | Temp 36.4 °C (Oral)  | Resp 26  | Ht 1.803 m  | Wt 76 kg  | SpO2 (!) 87%  | BMI 23.37 kg/m²    Physical Exam Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Murmur heard.  Pulmonary:     Effort: No respiratory distress.     Breath sounds: Rales present.  Musculoskeletal:     Right lower leg: Edema present.     Left lower leg: Edema present.  Neurological:     Mental Status: He is alert.     Motor: Weakness (generalized) present  4/15/22 H&P: CHIEF COMPLAINT        COVID-19 ASSESSMENT AND PLAN Principal Problem:   COVID-19 Pneumonia Active Problems:   hx of primary adenocarcinoma of lower lobe of right lung s/p wedge resection   Atrial fibrillation, persistent   Chronotropic incompetence   Cardiac pacemaker in situ   Chronic bilateral pleural effusions   Acute on chronic combined heart failure   Cardiac amyloidosis, transthyretin by endomyocardial biopsy   hx of respiratory failure due to COVID-19 Feb 2022   FTT (failure to thrive) in adult   Multiple myeloma   hx of Pneumocystis jirovecii Pneumonia Feb 2022 _________________________________________________________   Acute hypoxic respiratory failure -likely multifactorial 2/2 acute CHF, recurrence of pleural effusions, possible recurrence of COVID pneumonia, PJP pneumonia, or novel pneumonia of unclear etiology -CTA thorax negative for PE, positive for moderate pleural effusions, extensive parenchymal lung opacities suggestive of mixed resolving pneumonia and suspected new organized pneumonia, evidence of prior LLL lobectomy and RLL wedge resection, redemonstrated cardiomegaly with dual lead pacemaker in place, evidence of elevated right heart pressures and unchanged dilation of the aortic root -limited film array positive for COVID -infectious disease consult, await recommendations -interventional pulmonology consult, await recomendations -start empiric coverage with vancomycin and Zosyn -continue Decadron -check film array, sputum Cx, urine Legionella and strep antigen, MRSA screen PCR  -continuous pulse ox, wean to room air as able   Acute combined CHF exacerbation -BNP 9,882, increased from 6,168 on 4/7/22 -admitted for failure to thrive 4/6/22-4/11/22, infectious workup negative, Lasix and K-Dur were discontinued, PT OT recommended SAR but pt elected to return home with home PT -ECHO 4/7/22 showed EF 43%, moderate left ventricle global hypokinesis and moderate left ventricle hypertrophy -start Lasix 40 IV bid -monitor daily weights and I/O    Atrial fibrillation, prolonged QT, pacemaker, chronotropic incompetence, cardiac amyloidosis -follows with cardiologist -amiodarone discontinued in February 2022 -continue home Eliquis and tafamidis -Cardiology consult, await recommendations -telemetry   Hx of Pneumocystis jiroveci pneumonia -admitted from 2/17/22-3/5/22, bronchoscopy showed PJP pneumonia, treated with prolonged course of atovaquoune and prednisone, amiodarone was discontinued   Hx of pleural effusions -underwent outpatient thoracentesis with interventional pulmonology 12/13/21, pleural fluid transudative, PleurX drain placement suggested if effusions become recurrent   Hx of COVID pneumonia -admitted from 2/4/22-2/8/22 for COVID pneumonia with hypoxic, discharged on home oxygen, per pt was able to wean to room air    Multiple myeloma -follows with oncologist, was taken off of daratumumab in Jan 2022 due to recurrent illness DVT prophylaxis -home eliquis   Antibiotics, Antivirals, Antifungals -home Acyclovir -Vancomycin 4/15-present -Zosyn 4/15-present   Code Status  -DNR, pt does not want intubation or CPR per discussion at bedside    Disposition: inpatient admission for multifactorial acute hypoxic respiratory failure. Start multidisciplinary approach with infectious disease, interventional pulmonology, and cardiology consults. Start empiric Abx with Vancomycin and zosyn. Continue decadron. Pt's goal of care are clear, he does want to live and overcome acute illness, but is DNR. Likely to stay greater than 2 midnights  SUBJECTIVE   This is an 84-year-old male with a PMH of atrial fibrillation on Eliquis, chronotropic incompetence, pacemaker, combined CHF with EF 43%, multiple myeloma, hx of lung cancer s/p bilateral resection, immunocompromised on acyclovir, hx of bilateral pleural effusions, and a recent medical hx of pleural effusions s/p thoracentesis with Interventional pulmonology 4 months ago, COVID pneumonia 2 months ago, PJP pneumonia 1.5 months ago, and hospitalization for failure to thrive 4 days ago who presents with a CC of hypoxia x1 day.  Pt states he has not improved with outpatient physical therapy over the last month.  He states he had physical therapy come to his house today, he was noted to have a pulse ox as low as 84% on room air, and was sent to the ER for evaluation.  He is reporting shortness of breath with exertion and conversation.  He is reporting associated generalized weakness and poor appetite.  He states he wants to continue to fight to live but does not want CPR or intubation. In the ER the pt was found to be afebrile with pulse ox 86% on room air, stable on 4L supplemental oxygen.  CBC with WBC 9.3, Hgb 10.2, MCV 109.9, platelets 103, otherwise WNL.  CMP with protein 5.2, albumin 2.1, ALT 60, otherwise WNL.  HsTnT 140, repeat hsTnT 141, elevated BNP 9882. Lactic WNL.  Limited PCR positive for COVID infection.  EKG showed atrial flutter with atrial HR to 50, ventricular HR 106, Qtc 502. CTA thorax negative for PE, positive for extensive parenchymal lung opacities suggestive of mixed resolving pneumonia and suspected new organized pneumonia, evidence of prior LLL lobectomy and RLL wedge resection, redemonstrated cardiomegaly with dual lead pacemaker in place, evidence of elevated right heart pressures and unchanged dilation of the aortic root.  Pt was given a 500 mL IVF bolus, Decadron and transferred to facility for workup.     Review of Systems Constitutional:  Positive for appetite change. Negative for chills, diaphoresis and fever.  HENT: Negative for sore throat and trouble swallowing.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for shortness of breath. Negative for cough, wheezing and sputum production.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Negative for heartburn, nausea, vomiting, abdominal pain, constipation, diarrhea and trouble swallowing.  Genitourinary:  Negative for dysuria, polyuria and hematuria.  Musculoskeletal:  Negative for neck pain, back pain and falls.  Neurological:  Positive for weakness. Negative for headaches, dizziness, speech difficulty and numbness/tingling.  Endo/Heme/Allergy:  Negative for polydipsia.  Psychiatric/Behavioral:  Negative for sleep disturbance.  Skin:  Negative for itching and rash.  Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is ill-appearing.     Comments: Elderly  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard.    Comments: No peripheral edema Bilateral lower extremities with compression stockings Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds. No wheezing or rales.     Comments: Stable on 4L O2 Conversational dyspnea Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No deformity. Normal range of motion.     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Behavior: Behavior normal.     Comments: Cooperative, friendly