Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Pneumothorax, Productive cough, Prohormone brain natriuretic peptide increased, Pulmonary mass, Respiratory failure
Clinical narrative: Pfizer Dose 1 3/8/21 (EN6203) Pfizer Dose 2 4/2/21 (ER8734) COVID Positive 3/2/22  3/2/22: Patient is a 78-year-old female with past medical history of anemia, anxiety, arthritis, hypertension, insomnia with BMI 16 and recent unintentional weight loss that is presenting with recent onset shortness of breath. Presents today with her granddaughter and POA.  Patient is somewhat difficult to understand, therefore granddaughter is assisting with history.  Of note, patient's granddaughter believes her speech is worse than normal. Additionally, she has had a productive cough, upper respiratory symptoms, diarrhea, and chest pain over the past week.  Denies fevers, chills, nausea, vomiting. Appetite has been decreased.  She has taken some Tylenol for arthritic pain, has otherwise not taken any over-the-counter medications. Symptoms have all been progressive and they presented today to the emergency department for evaluation.   ED course:  Patient presented tachycardic at 1:14 a.m., 89% on room air.  Lab significant for:  AST 72, ALP 164, lactic acid 2.1, lipase 6, BNP 2 675; VBG showed pH 7.43, bicarb 34; CBC normal with MCV 106.8.  UA unremarkable, COVID rapid antigen and PCR positive, influenza negative. Chest x-ray showed bibasilar infiltrates, more severe on the left.  CT of the chest negative for PE, showed completely collapsed left lower lobe with patchy airspace disease in the middle and lower right lobe, concerning for pneumonia however an obstructing mass cannot be ruled out. CT of the head showed no acute findings, chronic atrophic changes and micro angiopathy disease.  Patient was given 500 mg of azithromycin and 2 g of Rocephin in addition to 10 mg of Decadron.  1 L normal saline administered.   Patient's granddaughter expresses concerns with patient's overall health deteriorating over the past several weeks. Patient lives at home, however is unclear if she is able to take care of herself sufficiently or not. She has refused nursing home care, granddaughter believes because she used to work in a nursing home. Patient is still driving, however there were some concerns about this.  Granddaughter believes that patient has been seeing an oncologist however she is not sure why this is the case.   Currently, the patient denies any acute pain and believes she is feeling better since arrival.  Breathing has improved.  Patient is admitted to the for for further management.  3/7/22: Pt. is a 78 year old female with pmh anemia, aniety, arthritis, HTN, insomnia and BMI of 16 with recent weight loss that presented on 3/2 with recent onset SOB. She is not on home oxygen. She has been vaccinated to COVID. Per patient's granddaughter, POA, patient had lost over 15 pounds unintentionally. Her appetite has been decreased over the past several weeks and she has not been eating. Overall she believes her health has been declining and she had not left her apartment in some time. Granddaughter states she has been seeing a hematologist/oncologist for anemia, but is unaware of any recent malignancies. She believes her speech has been more difficult to understand and she has also had a cough, URI, diarrhea, and chest pain that all started within the last week. When her shortness of breath progressed, her granddaughter urged her to go to the ED.   ED course per EMR: "Patient presented tachycardic at 1:14 a.m., 89% on room air.  Lab significant for:  AST 72, ALP 164, lactic acid 2.1, lipase 6, BNP 2 675; VBG showed pH 7.43, bicarb 34; CBC normal with MCV 106.8.  UA unremarkable, COVID rapid antigen and PCR positive, influenza negative.  Chest x-ray showed bibasilar infiltrates, more severe on the left.  CT of the chest negative for PE, showed completely collapsed left lower lobe with patchy airspace disease in the middle and lower right lobe, concerning for pneumonia however an obstructing mass cannot be ruled out.  CT of the head showed no acute findings, chronic atrophic changes and micro angiopathy disease.  Patient was given 500 mg of azithromycin and 2 g of Rocephin in addition to 10 mg of Decadron.  1 L normal saline administered."   Patient was admitted for hypoxic respiratory failure secondary to COVID-19. Pulmonology was consulted and she received rocephin, azithromycin, decadron, remdesivir, actemra, RT, and duonebs. CRP and D-dimer was trended. Patient's oxygen was weaned down to room air and pulmonology signed off.   In regards to her cachexia and weight loss, nutrition was consulted and assisted in supplementing diet. MR brain was obtained due to concern for malignancy given weight loss and lesion on CT chest that could not rule out mass. This showed no acute processes. Patient became intermittently confused, agitated, and combated as her mental status fluctuated, oftentimes refusing medications and meals. All medications that could be exacerbating her AMS were discontinued.   Her chronic conditions were initially managed with her home medications. Due to an elevated proBNP, an echo was performed which showed an EF of 40%.   Palliative medicine was consulted due to patient's deteriorating health status. They had a family meeting with patient's grad daughter, and she stated that her grandmother would want to transition to comfort measures and not suffer any longer than necessary. Hospice was consulted as a result. These comfort measures were initiated on 3/5 and all medications that were not contributing to her comfort were discontinued. Patient continued to receive prn medications to aid in comfort, however patient passed away on 3/7 around 1630. Family was present and was able to see her before transfer to funeral home.