Age: 58.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Blood culture, COVID-19 pneumonia, Culture, Death
Clinical narrative: Date of Admission: 12/28/2021. Date of Discharge: 01/21/2022. Reason for Hospitalization: Patient arrived via ambulance for reports of SOB. Patient states wife is COVID +.  EMS states patient SAT'ing 52% on RA. On NRB @ 91%. Duo neb given in route. Hospital Course: Patient is a 59 year old man with h/o type II DM, HTN, CAD (s/p PCI 2015), obstructive sleep apnea who presented for SOB admitted to the ICU on 12/28/21 for acute hypoxic respiratory failure secondary to COVID-19 PNA. Hospital course complicated by hyperglycemia transiently requiring insulin gtt. Completed remdesivir course and 10 days dexamethasone. [1] Patient's respiratory status and cardiovascular status continued to decline despite maximal treatments. Patient went comfort care on 1/21/22 and passed shortly afterwards with family at bedside at 630pm. Discharge Diagnoses: Hypo-osmolality and hyponatremia, Hypoxemia, Pneumonia due to COVID-19 virus, Tachycardia. Other Diagnoses: Ongoing Acid reflux, Anxiety, Colonoscopy, Depression, Dyslipidemia. Family history of: HX of non-ST elevation myocardial infarction (NSTEMI) 4/2015, Hyperlipidemia, Hypertension, Knee MCL sprain, Plantar fasciitis, Sinusitis, Tobacco abuse, Viral infection. Historical: Bilateral inguinal hernia, Nephrolithiasis, Vertigo induced by position of head or body. Consultants: Medicine Nephrology, Supportive/Palliative Care, Surgery Acute Care, Surgery General. Pending Labs: Blood Culture (Preliminary, In Process, ordered 01/17/2022, 22:30), Culture Blood (In-Lab, Ordered 01/21/2022, 09:33), Culture Blood (In-Lab, Ordered 01/21/2022, 09:33), QTL Culture (In-Lab, Ordered 01/21/2022, 09:33). Discharge Disposition: Passed away. Medications: New, Changed, or Refilled Medications, None. Medications to be Continued: acetaminophen (acetaminophen 325 m 650 mg, 2 Tablet(s), Oral, q4h, PRN: as needed for pain    albuterol (albuterol  HFA 90 mcg/i 2 Puff, Inhalation, q6h, for 30 day(s), PRN: Wheezing, 8.5 g, 0 Refill(s), aspirin (aspirin 81 mg , chewable) 81 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 11 Refill(s), atorvastatin (atorvastatin 80 mg) 80 mg, 1 Tablet(s), Oral, At Bedtime, 30 Tablet(s), 11 Refill(s), esomeprazole (esomeprazole 20 mg o 20 mg, 1 capsule(s), Oral, Daily, lisinopril (lisinopril 20 mg) 20 mg, 1 Tablet(s), Oral, Daily, for 30 day(s), 30 Tablet(s), 11 Refill(s) Comments: on completed med list and has established care Dr. 8/20, metFORMIN (metFORMIN 500 mg , extended 1,000 mg, 2 Tablet(s), Oral, Daily, 60 Tablet(s), 11 Refill(s), metoprolol (metoprolol succinate 1 100 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 11 Refill(s), multivitamin, prenatal (MULTIVITAM 1 Tablet(s), Oral, Daily. Discontinued Medications: None. Physical Exam at Discharge: Vitals & Measurements T: 36.2 °C  TMIN: 36.1 °C  TMAX: 36.4 °C  HR: 133  RR: 27  BP: 109/65  BP: 129/48(Line)  SpO2: 93%  WT: 75 kg. Please see Death Note. Nursing/Other Orders: Adult Tube Feeding, continuous. 01/19/22 8:54:00 CST, Replete - 1 kcal/mL, Goal Rate 90, route Nasogastric, how often Daily, Regular Diet. Ordered on 01/21/22 17:52:00 CST, Meal Start Time Breakfast 0700 to 0900, Intake and Output. 01/15/22 3:06:00 CST, Continuous Order, Elevate Head of Bed (Head of Bed Elevated). 01/18/22 10:25:00 CST, Continuous Order, to prevent aspiration; 30 Degrees, Fall Precautions. 01/15/22 22:12:11 CST. Order comment: order placed from nursing documentation CLIN_FALL_RISK, Up to Chair (Activity,  Up in Chair). 01/03/22 8:40:00 CST, tid w/Meals, Activity As Tolerated. 01/15/22 3:06:00 CST, Continuous Order. Code Status. Code Status Description: DNAR (Do Not Attempt Resuscitation). Oxygen Instructions. 01/21/22 17:52:00 CST, Routine, Instructions Titrate to comfort. No O2 Saturation Monitoring. Order comment: [1] MICU Progress/SOAP Note; 01/21/2022 07:20 CST