Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anion gap normal, Anticoagulant therapy, Arthralgia, Asthenia
Clinical narrative: "Deceased (11.25.21); Hospitalized (11.11.21); COVID-19 positive (11.18.21); Fully vaccinated with moderna x2  H&P: I have personally interviewed and examined the patient on 11/21/2021. Management was discussed with MD. I agree with the documented findings and plan of care in his/her note.   Brief exam:   Vitals:   11/21/21 1545 BP: 136/65 Pulse: 114 Resp: 18 Temp:     General appearance:  Alert, no acute distress HEENT:  Oral mucosa moist Respiratory:  Normal work of breathing, no wheezes crackles or rhonchi Cardiac:  Regular rate and rhythm no murmurs rubs or gallops Abdomen:  Nontender, nondistended no hepatosplenomegaly Extremities:  No peripheral edema, normal range of motion Integument:  No rash    Brief history and medical decision making:  Patient is an 85-year-old man with history of chronic obstructive pulmonary disease and who was vaccinated against COVID-19 in April 2021. He presented to the hospital with increasing shortness of breath and was tested positive for COVID-19 3 days ago on 11/18.  Patient said he was about to get his posterior but became ill before then.  When he presented to the emergency department his oxygen saturation was only 25%.  Patient was placed on high-flow nasal cannula at 100% and has been saturating in the mid 90s.  I had a discussion with him and his wife about code status.  Patient would prefer to be do not resuscitate/DNI.  If he continues to worsen he would like to be awake and able to visit with his wife as he passes away rather than on a ventilator.  Patient is very dehydrated and has not been able to drink water last several days and has had several bouts of diarrhea.  Patient was started on normal saline which will continue over the next 15 hours.  Will reassess and monitor closely for fluid overload in the setting of COVID-19 pneumonia.   History & Physical   CHIEF COMPLAINT:  Chief Complaint Patient presents with ? COUGH     cough, fever, fatigue, weakness x 2 days.  Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 85 y.o. male who presents with 7 days of symptoms including shortness of breath, productive cough, subjective fever, fatigue, weakness, chills.  He states he went to his PCP on Thursday 11/18/2021 and thought he just had a really bad sinus infection.  He was diagnosed with pansinusitis acute suppurative otitis media, and an acute upper respiratory tract infection and prescribed Augmentin.  He was also tested for COVID-19 and his PCP encouraged him to go to the emergency department for chest x-ray and COVID testing.  Patient stated at the time that he would go if he declined.  As symptoms worsened over the next few days, his wife drove him to the emergency department today.   Upon presentation, his pulse ox in room was 25% with a good waveform.  He was escalated to high-flow nasal cannula and was initially able to maintain sats in the low 90s high 80s.  Labs were obtained including CMP, BNP, procalcitonin, complete blood count, D-dimer, peripheral blood cultures.  CMP showed stable creatinine and GFR from outpatient records, otherwise relatively unremarkable.  Complete blood count with no leukocytosis.  Procalcitonin was elevated at 0.43, BNP was elevated at 2272, and D-dimer was elevated at 1440. The patient was started on gentle hydration with normal saline infusion per emergency department provider.  He was given a dose of dexamethasone and subsequently call was placed to admit the patient to the hospitalist service.   Upon my evaluation, spouse is at bedside and patient is lying on his left side with high-flow nasal cannula in place.  Despite max FiO2 and high-flow nasal cannula, patient is mildly dyspneic at rest.  He is using accessory muscles for respiration and discussion is talking only in 3-5 word sentences, often taking a break to take several breaths through his nose.  He endorses same symptoms as described above except for he says his diarrhea is no longer occurring.  We have a detailed discussion of code status and patient initially elects to be full code, designating his wife to make decisions if he is incapacitated.  Attending provider had further discussion with patient and after he was able to discuss this with his spouse and attending, decision was made to switch patient to DNR/DNI status.  He was subsequently admitted to general medicine service in guarded condition.   ED Course:  IV Dexamethasone 6 mg    Review of Systems Constitutional:  Positive for activity change, chills, fatigue and fever. Negative for diaphoresis.  HENT: Negative for congestion, rhinorrhea and sore throat.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough, shortness of breath and sputum production. Negative for wheezing and chest tightness.   Cardiovascular:  Negative for chest pain and palpitations.  Gastrointestinal:  Positive for diarrhea. Negative for nausea, vomiting, abdominal pain, constipation and blood in stool.  Genitourinary:  Negative for dysuria and hematuria.  Musculoskeletal:  Positive for joint pain (Left hip, chronic). Negative for edema.  Neurological:  Positive for weakness. Negative for headaches and dizziness.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Skin:  Negative for rash.  Reviewed 10 systems, pertinent findings included in HPI, all other systems are negative.    Objective    OBJECTIVE: BP 118/77  | Pulse 103  | Temp 99.5 °F (37.5 °C) (Rectal)  | Resp 17  | SpO2 96%  FIO2 (%): 100 %   Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is ill-appearing. He is not toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are dry.     Pharynx: No posterior oropharyngeal erythema.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Extraocular Movements: Extraocular movements intact.  Cardiovascular:     Rate and Rhythm: Tachycardia present. Rhythm irregular.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. No friction rub. No gallop.   Pulmonary:     Effort: Respiratory distress present.     Breath sounds: No wheezing or rhonchi.     Comments: Tachypneic, coarse crackles bilaterally, using accessory muscles.  Only able to talk in short sentences without taking a deep breath through his nose with high-flow nasal cannula. Chest:     Chest wall: No tenderness.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Lymphadenopathy:     Cervical: No cervical adenopathy.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not pale.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: He is alert.     Comments: Tremor noted right upper extremity, lower face and chin  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.  ASSESSMENT/PLAN:     COVID 19 Pneumonia Acute Hypoxic Respiratory Failure Sepsis Concern for superimposed bacterial PNA Presenting symptoms:  Shortness of breath, productive cough, subjective fever, fatigue, weakness, chills. SIRS criteria met, tachycardia, tachypnea COVID 19 detected by PCR:  11/18/2021. Symptomatic day: 7 (symptoms started 11/15) CXR with findings of moderately extensive left greater than right bilateral pulmonary opacities.. Received Decadron 6 mg x1 in ED. Procalcitonin 0.43 Current oxygen saturation 88%, oxygen requirement high-flow nasal cannula 100% FiO2 -Severe Respiratory isolation -Dexamethasone 6 mg oral daily 1/10 days -Remdisivir day 1. Will need daily CMP monitoring for liver and renal toxicities. -Daily labs CBC with differential, CMP, D-dimer  -Ins/Outs:  Goal even to net negative              -recent diarrhea, appears dry on exam              -will provide 100 mL/hour x15 hours -Continuous pulse oximetry and telemetry  -VTE prophylaxis subQ heparin -CAP abx coverage: start ceftriaxone and azithromycin x5 days     Chronic obstructive pulmonary disease No oxygen at baseline, no wheezing on exam Home:  Albuterol p.r.n. -Continue albuterol prn   Hypertension CAD Nonischemic cardiomyopathy Acute on chronic systolic and diastolic heart failure Frequent PVCs Follows was Cardiology Last echo 09/21/2020:  EF 49%, global hypokinesis, mild concentric LVH, grade 2 diastolic dysfunction.  Also noted moderate mitral regurg, mild AR, mild tricuspid regurg, mild pulmonary hypertension, severe left atrial enlargement and mild right atrial enlargement. LHC 2018: 30-40% left anterior descending artery, left circumflex artery and right coronary artery diseae BNP on arrival 2272 Home:  Amlodipine 10 mg daily -continue home amlodipine -update echo   CKD 3 Baseline creatinine 1.1-1.6, GFR 40-55 On arrival, creatinine 1.54, GFR 43   Prediabetes Last A1 c 08/05/2021 was 6.1% No home meds -will start VLD CSI in setting of initiation of steroids for COVID as above   Dyslipidemia Noted per chart review, no statin   Osteoarthritis Noted per chart review, uses tylenol prn at home   Peptic ulcer disease Noted per chart review, no meds at home -Will provide Protonix given initiation of PO steroids   S/p left hip replacement Noted   Familial benign essential tremor Noted, patient states this is unchanged since symptoms started 7 days ago     DVT: subq heparin GI: protonix Diet: general IVF: was placed on NS 125 ml/hr in ED -> will change to 100 mL/hour x15 hours Code status: DNR/DNI   Discharge /Deceased Summary: BRIEF OVERVIEW: Discharge Provider: MD Primary Care Physician at Discharge: PA-C Admission Date: 11/21/2021   Active Hospital Problems   Diagnosis Date Noted POA ? Acute hypoxemic respiratory failure due to COVID-19 11/21/2021 Unknown   Resolved Hospital Problems No resolved problems to display.   Pre-Existing Active Problems   Diagnosis Date Noted POA ? Coronary artery disease involving native coronary artery of native heart without angina pectoris 06/24/2021 Unknown ? Non-rheumatic mitral regurgitation 06/24/2021 Unknown ? Frequent PVCs 02/12/2019 Unknown ? Non-ischemic cardiomyopathy 02/12/2019 Unknown ? Hypertension, benign   Unknown ? Non-sustained ventricular tachycardia 11/29/2018 Unknown ? Primary osteoarthritis involving multiple joints 05/24/2017 Unknown ? Erectile disorder due to medical condition in male patient 11/18/2016 Unknown ? Prediabetes 03/30/2015 Unknown ? Dyslipidemia   Unknown ? Statin intolerance   Unknown   Date of Death: 11/25/21 Time of Death: 11:32 AM Preliminary Cause of Death: Respiratory failure   Discharge Disposition: Deceased   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute respiratory failure with hypoxia  [J96.01] Acute hypoxemic respiratory failure due to COVID-19  [U07.1, J96.01] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: Patient has a history of COPD, vaccinated with COVID in April, and presented to the hospital with acute hypoxic respiratory failure due secondary to COVID-19. He wished to be DNR/DNI. He was on CPAP with 100% FiO2 and unable to maintain his saturations. He was treated with decadron and remdesivir. He was also covered for community acquired pneumonia with azithromycin and ceftriaxone. His oxygenation continued to decline throughout his stay. He had a difficult time eating or drinking due to desaturations without CPAP. Discussed a feeding tube and he declined, but was given IV fluids for hydration. Due to continued decline, family decided to make him comfort measures the morning of 11/25.  He passed shortly after.    Death Pronouncement   Resident Team was called to bedside to pronounce patient death on 11/25/2021 Patient was unresponsive to voice, nail bed pressure  No cartoid or peripheral pulses were palpapable No visible chest rise noted Heart sounds were not heard Lung auscultation absent for any breath sounds Pupils were fixed, nonreactive to light Corneal reflexes were negative Time of death was 11:32 on 11/25/2021 Chaplain Services were offered: family declined Family was at bedside