Age: 93.0
Sex: M
Vaccine: COVID19
Symptoms: Endotracheal intubation, Explorative laparotomy, Extubation, Gastric ulcer perforation, Gastrointestinal fistula
Clinical narrative: Hospitalized; COVID-19 positive (fully vaccinated);  Expired in hospital (likely due to COVID-19)   BRIEF OVERVIEW: Admission Date: 8/22/2021 Discharge Date: 08/28/2021  Discharge Disposition: Deceased       DISCHARGE DIAGNOSIS:   1. Deceased 2. Perforated Gastric Ulcer 3. Acute Blood loss anemia 4. COVID19 5. AKI with CKD stage III 6. Acute Metabolic Encephalopathy       DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Respiratory distress   HOSPITAL COURSE: Patient was a 94-year-old male who was initially hospitalized with signs of septic shock believed to be secondary to COVID-19 and possible bacterial pneumonia; as well as new onset AFib with RVR.  Patient was admitted to the intensive care unit, he did have improvement initially with fluid resuscitation and Levophed as well as amiodarone infusion.  Further workup did reveal a pneumoperitoneum patient desired aggressive treatment and went forward knowing high risk of death with exploratory laparotomy.  This was done on 08/22/2021 and patient was found to have a pre pyloric perforation and peritonitis.  Patient was returned back to the intensive care unit and remained intubated along with central line placements.  Aggressive treatment continued, patient was extubated on 8/25 but not responding; further findings on repeat CT scans on 08/25 showed continued leaking from stomach as well as findings of a potential cancerous brain mass.  On 08/26/21 family, along with son, mutually agreed on comfort care initiation. Today at 0300 patient passed away, attempted son x3 calls, but then did get through to other son who was to notify the family.   HISTORY OF PRESENT ILLNESS: Patient is a 94-year-old man with a past medical history significant for CVA and mild dementia, CKD stage 3, hypertension and hypothyroidism who was admitted to intensive care unit on August 22, 2021 for COVID-19 infection and septic shock.   The patient was recently hospitalized from April 11th through April 15th for physical deconditioning.  During that time he was diagnosed with dementia with a MoCAa score of 6/30.  He discharged to Rehab where he has been continued undergo rehabilitation.  Today he presented to the emergency department in extremis.  He was in profound respiratory distress and shock.  He tested positive for COVID at his care facility a couple days prior.  This unclear if he had been undergoing any kind of treatment for this.  He had significant episodes of nonresponsiveness an apnea while in the ED.  Additionally, he was profoundly hypotensive and tachycardia with new onset rapid atrial fibrillation and rapid ventricular response.  He was hypothermic and placed on a Bair Hugger.  Initial blood work revealed mild electrolyte abnormalities, lactic acid greater than 7, a creatinine of 1.9.  Chest x-ray revealed mild scattered interstitial thickening and lung opacities.  Patient was started on IV fluid and placed on phenylephrine infusion.  Conversation with the patient's son, as well as his other son reveal that the patient would not want CPR or to be placed on a ventilator but they would want to pursue all other aggressive measures.  He was then transitioned up to the emergency department to the intensive care unit for further management.   Intensive care unit course: After arrival to the intensive care unit the patient was aggressively fluid resuscitated.  His blood pressures responded relatively well.  Due to pharmacy shortage of the phenylephrine the patient was transitioned to norepinephrine.  His cognitive status drastically improved from when I evaluated him in the emergency department.  He is alert and oriented x3.  Suspicious for ongoing COVID infection and possible pneumonia the patient's antibiotics were transitioned to cefepime plus azithromycin plus vancomycin.  He is started on remdesivir for COVID 19 treatment.  ABG revealed compensated metabolic acidosis.  The patient's lactic acid has improved to 6.5 from 7. Initial troponins are elevated as expected from demand ischemia from septic shock.  EKG does not reveal any ST segment changes in the patient does not complain of any chest pain.  He is, however complaining of abdominal pain.  He has a soft right inguinal hernia which is difficult to reduce and has no overlying skin changes.  The patient has had increasing oxygen needs initially requiring 6 L of oxygen in the emergency department now on 100% oxygen via non-rebreather.   At approximately 1630 while I was re-evaluating the patient and discussing his care to son the patient entered into a what appeared to be wide complex ventricular tachycardia with an initial heart rate of approximately 240. Nurse was in the room with me.  The patient was not feeling well.  His Levophed was shut off and fluids were started.  A stat amiodarone infusion of 150 mg was begun.  Patient was connected to defibrillator pads.  Asked the patient and family if he required cardiac defibrillation if he would want that, and he very explicitly said "yes!".  His heart rate responded to the amiodarone infusion, however, and he subsequently entered into what appeared to be a narrow complex supraventricular tachycardia with a heart rate of approximately 180. His blood pressure remained stable during this time.  As we continued to monitor in supportive care and continued his amiodarone infusion the patient's heart rate then entered into a normal sinus rhythm with a systolic rate of approximately 90. Unfortunately, strips of these rhythms were unable to be captured.  EKG afterwards revealed normal sinus rhythm with a first-degree heart block and previously seen right bundle-branch block.  After his amiodarone infusion I did not bolus further or start continued infusion for the patient but plan to continue monitoring.     Stat CT of chest abdomen and pelvis was obtained.  This revealed many things but specifically a pneumoperitoneum.  The case was discussed with the on-call general surgeon who evaluated the patient with me in the intensive care unit.  Along with the patient's son and other son, it was decided the patient would want to pursue aggressive measures including exploratory laparotomy.  Risks of surgery including death were shared with the patient.  Furthermore was explicitly stated that he would likely return to the intensive care unit ventilator dependent with multiple drains and need for central line and continued resuscitation the ultimate outcome of which being still high likelihood of death.  Understanding this the patient and his son still wanted to proceed.  Alternatives, including comfort care were offered and declined.     Of note additional findings on CT scan include nodular pulmonary opacities right with recommended CT follow-up in 3-6 months, left pleural effusion, and small abdominal aortic aneurysm and mild pulmonary fibrosis.