Age: 93.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Acute respiratory failure, Anticoagulant therapy, Anticoagulation drug level above therapeutic, Aortic stenosis, Bladder catheterisation
Clinical narrative: 11/22 Pt to ED with Shortness of Breath (pt reports ongoing SOB x one year progressively worse over 2-3 days and worse with exeration. pt c.o testicle swelling and fluid retention over 2 days. pt takes 2 of O2 at home. 89% in ED on 2 L of O2.) [Tested for COVID and resulted Negative]  11/23 Acute on chronic hypoxic respiratory failure: 2/2 above. 2L oxygen at home, currently requiring 3L. Monitor, goal O2 sat > 92%.  11/24 Acute-on-chronic systolic heart failure with evidence of volume overload / acute decompensated heart failure 12/1   He had a rough night.  He has fever, and is coughing up bile.  STAT XR chest and abdomen pending... COVID test reordered... Fever of 100.8 Fahrenheit.  12/2 COVID + test result, low grade fever persists 12/5 Systolic heart failure has improved. He is off Bumex infusion. Continue steroids, oxygen need stable at 3-4L. Some hematuria, continue to flush foley, trying to avoid CBI as patient likely will have more delirium  12/7 No new complaints noted; stable; no acute cardiac issues noted 12/8 Pt remains delerious, no acute complaints 12/9 Family still discussing the option of bringing patient home with Home hospice services. Family discussed case with their family cardiologist, whom they have a trusting relationship with. Writer discussed that the patient over all appears to be doing well. The main concern is with quality of life and the patient's wish to be home with family and stay out of the hospital setting overall. Will follow up with family regarding final decisions.  12/10 Family 100% sure they want to sign on with hospice services and take the patient home.  12/12 Remains a little delerious but is able to answer a few questions. No cough, fever or chills.  12/13 Family is undecided about hospice at this time. They would like to bring the patient home, but feel that since the patient is COVID positive they do not want to expose other vulnerable family members.  12/14 Discharged Total Brief Hospital Course:  Patient is a 93 yo M admited with acute on chronic systolic CHF. CXR showed congestion, evaluated by cardiology, started on IV diuretics and IV milrinone. 2d echo revealed EF 25%, mod-severe AS, severe LV dynsfunction. Upon iprovement, IV milrinone was discontinued. He was further found to have supratherapeutic INR, coumadin held and it was decided to switch AC to eliquis. During the course of the hospital stay he experiened increasing acute on chronic hypoxic respiratory failure, CXR showed opacities, found to be due to COVID19 pneumonia. ID consulted and started on appropriate treatments. Given age and comorbidities, palliative care was consulted and a discussion took place with family regarding goals of care, they declined hospice and opted for discharge to SAR instead. He completed treatments for COVID prior to discharge and was taken off of isolation. Cardiac medications were optimized as well. He will be discharged to SNF in stable condition. Follow up instructions provided.  All questions and concerns were answered and addressed prior to discharge with patient/family.  Prescriptions were provided.