Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Dyspnoea, Dysstasia, Electrocardiogram normal, Fatigue, Gait disturbance
Clinical narrative: Hospitalized (1.9.22 - present - still admitted); COVID-19 positive (1.6.22); fully vaccinated (no booster) Admitted 1.9.22: Chief Complaint - Patient presents with FATIGUE - Per EMS: pt from home, COVID x1 week; couldnt get up from toilet at 2100 on toilet all night; trouble walking and weakness; denies shortness of breath; 12 lead EKG NS; BG 125. History of Present Illness Patient is a 80 y.o. male who presents today with general weakness.  Last evening per EMS/triage patient was too weak to get up off commode. Patient's Covid symptoms reportedly for about 1 week. Patient is a difficult historian and he has no family at bedside. Patient tested positive for COVID-19 on 01/06. Patient denies any chest pain or dyspnea that is worse than baseline.  Patient denies any nausea or vomiting. Patient states he has been eating fair.  Patient reports chills but denies any fevers or diaphoresis.  Patient reports diarrhea has improved but per records was having some accidents at home.  Patient denies any melena or hematochezia.  Patient reports a productive cough with greenish sputum.  He denies any pleuritic chest pain.  Patient denies any worsening of his lower extremity edema.  He walks with a walker at baseline reports significant generalized weakness especially over the last 24-48 hours.  Patient denies any falls or trauma.  Patient tells me does not use home oxygen and he no longer uses his BiPAP or it his inhalers at home.  Information is obtained from EMR, patient is a limited historian. According to EMR patient's spouse has Covid.  Patient has had J and J vaccine but both he and spouse declined boosters.   Patient has past medical history of chronic atrial fibrillation on oral anticoagulation, chronic obstructive pulmonary disease, bronchiectasis, obstructive sleep apnea, s/p AVR and MVR, PM&R, hyperlipidemia, coronary artery disease.  Left echocardiogram 11/05/2019 LVEF of 54%. In the emergency room patient was evaluated his chest X showed possible left mid lung infiltrate.  With ambulation patient's oxygenation saturations decreased to 88%. During my evaluation patient had significant generalized expiratory wheezing the his saturations on 3 L nasal cannula were 96%.  He had no conversational dyspnea. Patient's procalcitonin 0.13, creatinine up from baseline slightly 1.18, hemoglobin stable 14.5. Patient was started on Decadron 6 mg IV and internal medicine service was asked to admit patient for observation for generalized weakness and hypoxia with possible early COVID pneumonia on chest x-ray on left with right sided atelectasis. Principal Problem: Pneumonia due to COVID-19 virus Covid Pneumonia developing Acute hypoxia, denies home oxygen J and J vaccine, declined booster (spouse w/covid) Covid sx onset not clear from patient, reported EMS x 1 week 88% sat w/ambulation, currently on 2L 94% Covid (+) 1/6, presents to ER 1/9 w/increased weakness Ambulatory O2 sats  covid appropriate labs x 3 days CXY possible early left lower, atelectasis right mid/basilar PCT 0.13 Decadron 1/9 - Continuous pulse ox Symptomatic treatment Severe respiratory isolation Encourage C and dB Progress Note from 1.18.22:  Patient admitted to HOSPICE SERVICES:  Hospice GIP admission: Referral received for hospice informational visit/GOC conversation.  Met at 1300 with pt, spouse and daughter in pt's room.  Pt on 100% FiO2 with sats in the mid to high 80's at rest.  Feet purple.  It complaining of neck pain and dry mouth. This was pt's initial visit with these family members this hospitalization. Pt coughing with oral intake. Reviewed with pt hospice referral and general comfort measures. Met in conference room with pt's son and daughter. Reviewed pt's condition and answered questions related to care.  Discussed goals of care and pt's main desire for comfort.  Reviewed DNR/DNI, comfort care, and hospice services.  Additional meetings throughout the afternoon and evening with pt and family. Dr consulted and spoke with family. Chaplain offered and declined per family. Son is Proxy and updating additional family members. At evening meeting family all in agreement to honor pt's request for comfort and proceed with GIP admission and withdrawal of hiFlow support. Hospice certification from the hospice doctors. Orders received for: Fentanyl continuous infusion 75 mcg/hr with 100 to 125 mcg boluses PRN every 10 minutes pain/dyspnea Versed continuous infusion 2 mg/hr with 4 to 6 mg boluses PRN every 10 minutes anxiety. Hiflow removed once pt was relaxed. Stats dropped immediately to the mid 60's. Provided boluses during power hour: Fentanyl 450 mcg  Versed 20 mg  Pt continues with periods of apnea followed by labored respiration. Unable to get O2 sat reading.  Extremities cool and dusky Communication with Dr and rate adjustment to: Fentanyl 150 mg/hr Versed 6 mg/hr Added Robinul 0.2 mg IVP every 4 hour Funeral Home: Family to discuss with additional family members tomorrow and will notify hospital supervisor with number provided. Care coordinated with BS RNs, and RT. Support provided to family. Thank you for allowing hospice to assist in the care of this patient. Please call with any questions or concerns.