Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Sepsis, Septic shock, Skin lesion, Skin warm, Skin weeping
Clinical narrative: Patient vaccinated for COVID on 2/17/2021, admitted on 8/3/2021, tested positive for COVID 8/3/2021. discharged 8/8/2021 patient admitted again on 8/23/2021, tested positive for COVID 8/23/2021.  Patient passed away on 9/4/2021  History Of Present Illness a 80 y.o. male with a PMH of A-fib (on Eliquis), severe MVR, HTN, HLD, CAD s/p 2xDES (2005), Saddle PE (2017), reduced LVEF, Waldenstrom macroglobulinemia (on imbruvica) who presents with worsening weakness, dizziness, SOA, chills and decreased appetite over the past 1.5 wks. Associated with mild abdominal pain. Symptoms started back in June, but acutely worsened. He was evaluated for these issues. His cardiologist performed a LHC showing 50% LAD stenosis, severe MR, LVEF 30-35%, LVEDP of 40. Given these findings, he was referred to another doctor for evaluation for potential MV replacement. However, given his worsening symptoms, he presented to the ED. Patient denies recent sick contacts. No fevers, N/V/D. He is vaccinated against COVID. He was given lasix to take for 2 wks if he had significant weight gain- states he only took it 3 times and had not since. Compliant with all meds.   Review of Systems  Constitutional: Positive for activity change, appetite change and chills. Negative for fever.  HENT: Negative for trouble swallowing.   Respiratory: Positive for shortness of breath. Negative for cough, chest tightness and wheezing.   Cardiovascular: Positive for palpitations and leg swelling. Negative for chest pain.  Gastrointestinal: Positive for abdominal pain. Negative for constipation, diarrhea, nausea and vomiting.   Assessment and Plan   He is an 80 y/o male with PMH of A-fib (on Eliquis), severe MVR, HTN, HLD, CAD s/p 2xDES (2005), Saddle PE (2017), reduced LVEF, Waldenstrom macroglobulinemia (on imbruvica) who presents with worsening weakness, dizziness, SOA, chills and decreased appetite over the past 1.5 wks  noted to have Covid Infection.      #COVID Infection  -Now needing 3 l of O2  -CXR- Peribronchial thickening and interstitial opacification may be associated with viral infection -Patient states he was previously vaccinated.  -Given patient's hypoxia, will start dexamethasone 6 for 10 days and also Remdesivir  -Encourage Pul toilet, BD and Proning  -Monitor    AKI on CKD -baseline Cr 1.6 -Likely due to prerenal in the context of IV lasix on admission with N BNP -Monitor in the background of Remdesivir -Hold further diuresis  -avoid nephrotoxic agents  -Repeat CMP in AM    #Severe Mitral Regurgitation #Mitral Valve Prolapse #HFrEF #CAD s/p DES - Baptist LHC 6/22/2001 - 50% LAD stenosis, severe MR, LVEF 30-35%, LVEDP of 40 - ECHO 12/2015 - bileaflet prolapse with posterior mitral cleft with severe MR.  - ECHO 8/2018- shows MV prolapse with severe MR.  - ECHO 6/30/2021- severe MR. No sig mitral valve stenosis is present. LVEF 45-50%. - BNP- 864, Na 135, Cr 1.6 (baseline).  - CXR- Peribronchial thickening and interstitial opacification may be associated with viral infection A/ Overall believe patient's symptoms are 2/2 to Covid infection and his worsening, severe MR. He was diuresed well with 40 of IV lasix. Will have evaluation from CT surgery. If they believe valve is the root cause of his issues and do not feel surgical intervention is warranted, will consider interventional cardiology consultation.  Plan: - CT Surgery Consulted - Hold further diuresis given severe MR and improvement in symptoms    #A-fib  - Patient on eliquis and atenolol  -C/w eliquis and atenolol    #Waldenstrom macroglobulinemia - Started on imbruvica for treatment. Patient states he does not take venclexta  Plan: - Consult oncology in AM for approval of imbruvica    Chronic Conditions  -Benzodiazepine dependence- Tranxene 15 mg nightly; recommended weaning and discontinuing as outpt  -Skin Lesions- multiple lesions on abdomen and UEs- continue doxycycline.  -HLD- pravastatin 40 -HTN- on atenolol only  -GERD- PPI   F: po E: po N: Cardiac, low salt;  DVT Ppx: Hold eliquis, heparin 5000 q8hrs   Code:code status: do not resuscitate, okay to intubate. POA- Son. Has living will.   Hospitalization Admit Date/Time: 8/3/2021  9:47 AM Discharge Date: 08/08/21     Chief Concern, Brief History of Present Illness, and Hospital Course He is an 80 y.o. male with a history of A-fib (on Eliquis), severe MVR, HTN, HLD, CAD s/p 2xDES (2005), Saddle PE (2017), reduced LVEF, Waldenstrom macroglobulinemia (on imbruvica) who presents with worsening weakness, dizziness, SOA, chills, mild abdominal pain and decreased appetite over the past 1.5 wks and noted to have Covid Infection. He was here for the mitral valve surgery and found to have COVID. He transiently required oxygen and was off oxygen at the time of discharge. He was treated with dexamethasone and remdesivir. Hematology advised to hold ibrutinib in the setting of COVID infection and upcoming surgery and follow up with patients OSH hematologist to decide about ibrutinib. CTS will follow up with the patient regarding surgery which is likely to be in a month as per my discussion with CTS. The details of A&P while in the hospital is listed below.    #COVID Infection # Acute Hypoxic Respiratory failure (resolved) -discharged on room air.  -CXR- Peribronchial thickening and interstitial opacification may be associated with viral infection -Patient states he was previously vaccinated.  -Given patient's hypoxia, c/w dexamethasone 6mg  for 10 days and Remdesivir     AKI on CKD-Resolved.  Discharge Disposition/Condition Disposition: Home Condition: Stable (s/sx potential problems absent or manageable)  second admission 8/23/2021 Patient admitted for altered mental status  Chief Complaint Chief Complaint Patient presents with ? Trauma Alert ? Fall ? Epidemic Concern ? Altered Mental Status     History Of Present Illness   He is an 80 yo male with PMH waldenstrom macroglobulinemia (on imbruvica), Afib (on Eliquis), severe MVR, HTN, HLD, CAD s/p 2xDES (2005), Saddle PE (2017), reduced LVEF.  Who presented to the Emergency Department after a fall at home.  History is obtained from son who is at bedside and prior records as patient is currently altered and minimally responsive to exam.   Per the son the patient had become increasingly confused over the past 2 days where he was "talking off the wall".  After falling to his left side, son brought him to emergency department for further evaluation.  On arrival the patient was saturating in the low 80s on room air and tachycardic to 120s with normotension.  He was administered 2 L of fluid and placed on high-flow nasal cannula.  His oxygenation improved, however he developed A-fib RVR with HR up to 180s.  His blood pressure dropped with this to maps in the low 70s.  At this time MICU was consulted for further evaluation.   On exam the patient is altered, alert to person only.  He also has notable swelling and erythema to his left forearm which is hot to touch.  Noteworthy labs include WBC 20.67, Creatinine 2.15, and Lactate 4.5.  Patient will be admitted to ICU with plan for Amio gtt for A-fib RVR and management of Sepsis.   Pulmonary:    Breath sounds: No stridor. Decreased breath sounds present. No wheezing or rhonchi.  An 80 y/o male with PMH of Afib on Eliquis, severe MVR, HTN, HLD, CAD s/p DES. PE (in 2007), HFrEF (50% EF), CKD, Waldenstrom macroglobulinemia, recent COVID infection who is being admitted for sepsis likely 2/2 SSTI of L arm.   #Sepsis and Septic Shock - Patient presented with F 101.2F, Tachycardia, tachypnea, hypotension and had elevated WBC at 20.67 - L arm swollen, erythematous, warm to touch and weeping. L arm cellulitis appears to be the likely source. - Blood cultures pending. Check urine cultures, sputum cultures, S pneumo and legionella. - S/p Vanc and Zosyn. Continue broad spectrum antibiotics and tailor them pending culture results. - 2L fluid given in boluses. Due to HFrEF will hold off on any more IV boluses. Can give gentle maintenance fluids. - Lactic acid elevated at 4.5. Follow post resuscitation levels. Dispo - Admit to ICU - DNR/I  a 80 y.o. male with past medical history significant for atrial fibrillation on Eliquis, severe mitral valve regurgitation, hypertension, hyperlipidemia, chronic systolic heart failure, CAD, previous saddle PE, Waldenstrom macroglobinemia, and critical aortic stenosis, who presented to ED with after a fall at home. Per report, the patient was diagnosed with COVID-19 on the 3rd of this month and has been living with his son while he has been recovering. Of note, the patient was due to undergo evaluation for surgical repair of his symptomatic valvular heart disease, however this was postponed due to his COVID-19 infection. His son states that for the past 2 days, he has become increasingly confused with worsening mentation from his baseline. His son noticed that his father became acutely tachypneic today and suffered a mechanical fall from standing, landing on his left side. He was brought to the ED as a trauma alert with subsequent workup significant for oxygen saturation of 84% on room air, tachycardia with HR between 150-180, and breathing at 30-35 breaths per minute. He was given 2L of fluid, IV antibiotics per sepsis protocol, and Tylenol for symptomatic relied. He continues to be tachycardic in the 170's on average at this time with high flow nasal cannula required for adequate oxygen saturations above 90%. Hospital medicine was consulted for admission given concern for this patient's clinical presentation and unstable vital signs.    He was eventually endotracheally and transferred to the ICU for further care. He was treated for assumed pneumonia and on workup was found to have severe mitral regurgitation. With diuresis and antibiotics, the patient's mechanical ventilation was eventually weaned and the patient was extubated. CTS was consulted for his severe MR and potential surgical options, however given the patient's age and level of illness and debilitation, this was not possible. The family was consulted at every stage of the decision making process and they elected to make him DNR/DNI and palliative care was consulted. On 9/3 comfort care measures were instituted and the patient passed away peacefully with his family at bedside.    Hospitalization Admit Date/Time: 8/23/2021 11:42 AM  Discharge Date: 9/3/2021  1.  Severe mitral regurgitation with respiratory failure- patient and his son understand that there are longer medical or surgical options for his valve disease.  Their goal is to focus on comfort care duing his last days of life.   It is important to them that he lives for the next several days in order for his son to complete the sell of patients  home on Tuesday.  This will allow them to avoid escrow and gift the house to a family that is important to him.   Should he decline to dying before then we will not attempt to prolong his life. However in the interrim we will continue hi flo oxygen as any attempt at weaning will shorten life now.   Will also continue tube feeds but allow to eat and drink for pleasurer and not replace tube if becomes removed.    Comfort Care Only   Goals of care- comfort care plan, allow natural death with no escalation of care -can dc lab draws -do not increase oxygen supplementation past current hi flo setting  -can stop telemetry, rapid response -dc scd -allow food and drink for pleasure  Patient Expired during this admission and was discharged to morgue.