Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Blood pressure increased, Brain natriuretic peptide increased, Breath sounds absent, COVID-19, Cardiac telemetry
Clinical narrative: Deceased (11.21.21); Hospitalized (11.11.21); COVID-19 positive (11.11.21); Fully vaccinated  ASSESSMENT / PLAN: * Hypokalemia severe Assessment & Plan Severe hypokalemia Orally and IV potassium replacement Suspect a combination of diarrhea as well as hydrochlorothiazide Hold hydrochlorothiazide consider starting a set discharge instead of hydrochlorothiazide Hypomagnesemia likely contributed as well Intensive care unit on telemetry monitoring until potassium has significantly improved   Hypocalcemia Assessment & Plan Suspect related to poor oral intake as well as severe hypomagnesemia IV replacement Replace magnesium Suspect will improve calcium level with magnesium replacement   Hypomagnesemia Assessment & Plan Suspect due to hydrochlorothiazide and or diarrhea IV replaced   COVID-19 Assessment & Plan Patient vaccinated likely explaining why her oxygenation is so good. No indication for dexamethasone or remdesivir Main symptom is diarrhea Continue respiratory isolation   Generalized weakness Assessment & Plan Suspect multiple factors including all of her electrolyte abnormalities on baseline weakness PT OT   Essential hypertension with goal blood pressure less than 140/90 Assessment & Plan Blood pressure elevated in the ER will follow. Holding hydrochlorothiazide Consider changing to lisinopril at discharge.  Or during hospitalization if antihypertensive needed.    Discharge Disposition: Deceased   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypocalcemia [E83.51] Hypokalemia [E87.6] Hypomagnesemia [E83.42] Diarrhea, unspecified type [R19.7] COVID-19 [U07.1]   HOSPITAL COURSE: Patient was admitted 11/11/21 with main complaint of weakness, as well as diarrhea, fever, chills, and cough.  In the ER she was found to be COVID positive and hypokalemic with a potassium of 2.0.  She had been vaccinated for COVID and was not hypoxic at time of admission.  She was initially placed in the ICU while potassium was replaced.  She was eventually started on IVF for hyponatremia.  On 11/13, the patient had a choking episode while taking pills, which resulted in hypoxia and shortness of breath. She had a history of "tight esophagus" but did not want to have repeat dilation per daughter. That evening the patient complained of chest pain and nausea.  EKG revealed sinus tachycardia with occasional PVCs.  BNP was markedly elevated at 32,400 and troponin was 206.  CXR showed atelectasis.  IVF were discontinued and she was given IV lasix for suspected fluid overload.  Heparin drip was started for suspected NSTEMI and nitro paste was placed.  She received ASA, statin, and beta blocker.  She was started empirically on antibiotics to cover for potential aspiration pneumonia.  The patient did not desire cardiac intervention.  SLP evaluated the patient and suggested thin liquids with medications crushed in puree or liquidized.  Echocardiogram was obtained and notable for diffuse apical akinesis and an EF of 21%.  This was discussed with cardiology and felt to likely be takotsubo cardiomyopathy.  Her weakness and hypoxia continued to worsen.  She continued to be diuresed.         The evening of 11/17 the patient expressed thoughts of transitioning to comfort care.  11/18 she stated that she did not want to continue aggressive medical therapies.  Family was in support of this decision and Hospice was consulted.  The plan was that she would transition to hospice care at discharge.  She was given medications as needed for restlessness and pain.     The early morning of 11/21, Patient had very shallow respirations.  She was pronounced dead at 3:26 on 11/21/21.  On exam she was unresponsive, pupils fixed and dilated, no pulse, no breath sounds, and no heart tones.  Daughter was notified.  Funeral home arrangements pending.