Age: 72.0
Sex: F
Vaccine: COVID19, COVID19, FLUA4
Symptoms: Anticoagulation drug level above therapeutic, Antinuclear antibody positive, Asthenia, Atrial fibrillation, Blood test normal
Clinical narrative: Patient is now DECEASED;  Hospitalized (12.11.21 - 1.20.22); COVID-19 positive (1.4.22); Fully vaccinated (no booster) Admission Date: 12/11/2021 Date of Death: 1/20/22 Time of Death:  3:04 PM Preliminary Cause of Death: Acute encephalopathy DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Tachypnea Failure to thrive in adult AKI (acute kidney injury) Atrial fibrillation with rapid ventricular response Atrial fibrillation with RVR Altered mental state  Sepsis   HOSPITAL COURSE: Patient is a 73 year old woman who was recently admitted to hospital and had extensive work up for fever presented with altered mental status. She was on bactrim for concern for toxoplasma infection. She was found to have a.fib with RVR as well. She was started on IV cardizem. Echo was normal. Cardiology was consulted for assistance with rate control. She was transitioned to lopressor and digoxin with improvement and weaned off cardizem gtt.    Neurology consult was obtained. She had MRI, LP and EEG. All of them did not reveal any organic etiology for her presentation. As her mental status did not improve, corpak was placed and she was started on tube feeds. ID consulted for toxoplasma infection. Unclear if patient with active infection Bactrim initially continued and stopped due to LFTs trending up given low suspicion for active infection and completing extended antibiotic course from admission at hospital recently. Karius test was ordered and was negative.   Overnight on 12/24, pt was found to be tachycardic, tachypneic hypotensive and hypoxic. A RAP was called, pt was given 3 L IVF and 3 doses of albumin with slow improvement of blood pressures. She was quickly weaned back to RA. Her hgb was found to have dropped to 7.0 and 1 unit PRBC ordered. She had CT thorax which did show right upper lobe PE and CT abd/pelvis showing proctitis. US showed bilateral LE dvt. Her Eliquis was changed to Lovenox. GI was consulted with acutre drops in hgb and felt no acute GI bleed. Pt then had worsening fevers, tachycardia and tachypnea on 12/26. She had repeat CT Angio thorax which showed worsening clot burden. A LMWH level was checked and found to be supratherapeutic. Hematology was consulted and she was switched to heparin drip. Neurology was reconsulted with ongoing AMS and fevers. She was moved to ICU as CC2 for closer monitoring. Patient remained stable over the night in the ICU and transferred back to the general floor. Heparin gtt continued as patient had a decrease in hgb, may transition back to eliquis if hgb stabilizes. Lasix resumed, but minimal output even with addition of metolazone and eventually transitioned to lasix drip that was weaned off. She continued to require intermittent diuresis.    With persistent encephalopathy, neurology and ID was reconsulted. Repeat LP was done 1/5/22 with a negative CSF. A repeat 2 hour EEG 1/12 continue to show moderate encephalopathy. Per ID 1/12 no further infectious work up recommended unless increased fever curve and new leukocytosis. Rheumatology was then contacted who recommended checking ANA and Anti Ds DNA. ANA and anti smith antibody found to be positive. She was started on plaquenil 400 mg daily for possible lupus cognitive impairment.    She continued to have persistent tachycardia and tachypnea. She was originally seen by cardiology. She was started on metoprolol, dilitiazem, and digoxin with some improvement in HR however still at times elevated. She had persistent tachypnea as high as 60. Her O2 remained stable. Did not note any improvement with suctioning. The patient was positive for COVID 1/4/22. Remain on RA and imaging with mild disease burden. She also continued to receive intermittent diuresis. She was then started on morphine for work of breathing.    The patient was noted to be anemic and required multiple blood transfusions. Could consider GI evaluation once hemodynamically stable.   She was also noted to have persistently worsening sacral wound. Wound was consulted who recommended dressing changes, offloading. Concern for pressure ulcer vs kennedy ulcer. Noted that may need to consider plastics for debridement in OR however pt too hemodynamically unstable to pursue.   With prolonged hospitalization, palliative, hospice and ethics were consulted. Family was agreeable to change code status to DNR/DNI. Hospice continued to follow. Family wanted to wait to see after initiating plaquenil if any improvement in mentation in 7-10 days. Mentation failed to improve. On 1/19, she was transitioned to comfort care and was admitted under inpatient hospice status. She was started on morphine and versed infusions. Multiple family members were present at bedside. The patient passed away at 3:04 pm on 1/20/22. Hospice present and will follow up with family for funeral home selection.