Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Anion gap, Anisocoria, Anticoagulant therapy, Atrial fibrillation, Barium swallow abnormal
Clinical narrative: Date of Admission  01/20/2022   Date of Discharge  02/04/2022   Reason for Hospitalization   found down unresponsive  Hospital Course       Patient is a 82 y/o M w/ Persistent afib on Xarelto, NICCM w/ HFpEF (EF ~50%) w/ -LHC in 2019, remote tobacco use, HTN, HLD, and BPH who presented to the ICU from the ED after being bought in by EMS for severe hypothermia, hypoglycemia, and obtundation. Pt received several amps of D50W en route. In the ED, the patient was noted to still be lethargic initially. Vitals were concerning for mild hypoxemia, moderate hypothermia, and hypotension. Labs showed +Covid, mild rhabdomyolysis, Hypernatremia, AKI (Cr 1-- >1.5), HAGMA and NAGMA (Ag=17), Troponin elevation, and transaminitis. He received 3 L of fluids in the ED.  Initial EKG revealed sinus rhythm with frequent PVC's, notable J waves and T wave inversions noted in V4 to V6. Chest x-ray showed pulm edema w/ Possible pneumoperitoneum.  CT head revealed a scalp hematoma with no acute intracranial abnormalities. Completed Vancomycin and meropenem for pneumonia. CT neck showed no fractures. Ct A/P showed liver disease and anasarca. Patient was intubated 1/21-1/25. Weaned down to 2-3 L NC. While in ICU was started on tube feeds, post extubation; patient failed multiple swallow evaluations. PT/OT following, SNF recommended. After multiple goals of care discussions with patient, family, and palliative care; decision was made my patient's DPOA to make patient DNR/DNI and initiate comfort care orders. Patient to discharge to hospice.  Discharge Diagnoses      DC plan:  -DC to hospice  - hospice  -mechanical soft diet  Comfort Care:  After multiple goals of care discussions involving the patient, myself, family (including patient's DPOA), and palliative care. Decision was made by (DPOA) to make patient a DNR/DNI and initiate comfort care orders. Dr. was present for this conversation.  On 2/3 family wished to discuss feeding tube placement again, after multiple discussions with (DPOA) via phone and sister at bedside, decision was ultimately made to forgo a feeding tube and continue comfort feeds with mechanical soft diet, Dr. was present for this decision. Family okayed patient to go to hospice.  -CM set up hospice prior to DC  -comfort care orders initiated  -palliative care consulted   ___________________________________________________________________________________  Rectus sheath hematoma: Stable  Hgb had been down trending, abd exam concerning for hematoma.  -CTA abd showed rectus sheath hematoma w/o evidence of active bleed  -stopped Xarelto  -monitor hgb, has been stable  -monitor fo s/s of active bleeding  Acute respiratory failure with hypoxia: Improving  2nd to COVID, pulmonary edema, and aspiration pna.  Stable on 2-3 L NC.  -intubated 1/21-1/25  -wean O2 as tolerated  -monitor oximetry, encourage IS  COVID PNA: Resolved  Aspiration PNA: Resolved  COVID + on 1/20/22. Vaccinated x2 w/ Moderna. Off precautions 1/30.  -dexamethasone (1/21-1/30)  -held IV remdesivir given renal function  -PNA PCR 1/22 (+ ecoli, Moraxella, proteus, pseudomonas, s. aureus)  -1/20 blood cx + for strep warneri, repeat cx 1/21 NGTD  -QTL cx grew s. aureus  -trend infectious/inflammatory markers  Antibiotics:  -Vancomycin 1/20-1/27  -Meropenem 1/20-1/27  Anasarca: Improved NICCM w/ HFrEF:  Essential HTN:  PTA reportedly on lisinopril 20 mg qd and metoprolol succinate 100 mg qd.  EF 15% on 1/21/22 (EF previously ~50%). BNP>20K on admit. On Lasix 20 mg qd as outpatient.  -Cardiology consulted in ICU  --stopped home metoprolol  --started carvedilol 3.125 mg qd, stopped for comfort care  --recommend adding ACE/ARB when BP will tolerate  ---start lisinopril 2.5 mg qd 1/31, stopped for comfort care  --p.r.n. diuresis, strict I&O, daily weights  --restart patient's home Lasix 20 mg qd 1/31  --"Given recent negative LHC, no likely benefit of cath at this time."  Oropharyngeal dysphagia:  -continue tube feeds via NG tube  -SLP consulted, patient did not pass swallow eval 1/28, SLP re-evaluated 1/31 and still recommending NPO  -Barium swallow study w/ SLP on 2/3, patient failed, significant aspiration noted with all intake  -family/DPOA ok with comfort feeds with mechanical soft diet  ?stroke-like symptoms:  Code stroke called on patient 1/27, per nursing patient had increased lethargy, unequal pupils, and left sided facial droop. Acute imaging and labs was negative for acute findings. Neurology evaluated patient, stroke r/o, signed off.  -brain MRI negative for acute findings  Acute encephalopathy: Improved  A&O at baseline. Ammonia wnl. CT head/neck unremarkable aside from external scalp hematoma.  Suspected 2nd to acute illness. Patient's mentation waxes and wanes, oriented at times.  Persistent afib:  Has Xarelto on home med list, unclear if he was taking as prescribed.  CHADS2-Vasc: 3.  -stop heparin drip and restart home Xarelto 1/27, stopped Xarelto 1/29 for hematoma/anemia  -home metoprolol stopped  --started on digoxin for rate control 1/27, stopped on comfort care  CKD S2:  Baseline Cr 1-1.2.  Transaminitis: Improving  Patient had evidence of liver disease on his CT and US. RUQ US shows fatty liver and cholelithiasis. Hx of alcohol abuse.  Hypocalcemia: Resolved  Hypophosphatemia: Resolved   Thrombocytopenia: Resolved  Macrocytic anemia:  -1/28: iron 61, TIBC unable to calculate, VB12 1131, ferritin 848, iron sat unable to calculate  Moderate protein-calorie malnutrition:  Albumin 1.9.  -tube feeds  -SLP recommending NPO, on comfort feeds  -no feeding tube recommended per palliative care  Depression:  PTA reportedly on mirtazapine 15 mg qd as outpatient.  -held home meds in setting of encephalopathy  HLD:  Previously on atorvastatin 40 mg qd as outpatient, unclear if still taking.  GERD:  PTA reportedly on omeprazole 20 mg qd.  -on ppi per formulary, stopped med on comfort care  BPH:  PTA reportedly on oxybutynin and tamsulosin.   -void trial completed  -unable to crush tamsulosin, started doxazosin per tube  ---stopped doxazosin on comfort care  Hx of alcohol abuse:   Patient and family are unable to quantify how much patient drinks. Patient states he drinks beer and mixed drinks every day.  -received thiamine per tube  -no s/s of withdrawal during hospitalization  Right foot wound:  Possibly frostbite. See media. Patient on abx.  -skin team consulted  Allergic rhinitis:   PTA reportedly on cetirizine and loratadine as outpatient.  Resolved in ICU:  -hypothermia  -hypernatremia  -AKI  -HAGMA  -starvation ketosis  -hypoglycemia  -mild rhabdomyolysis   This patient was discussed with Dr., please see their attestation for any further management.  Disclaimer: This note was dictated by speech recognition using software. Minor errors in transcription may be present. Please call if questions.  Other Diagnoses   Ongoing  Atrial fibrillation  Benign prostatic hyperplasia  Cardiomyopathy  History of IBS  Hyperlipidemia  Hypertension  Sinus arrhythmia  Historical  No qualifying data  Operations and Procedures   N/A  Consultants  Family Medicine General    Medicine Cardiology    Supportive/Palliative Care   Pending Labs  N/A  Discharge Disposition  Hospice  Medications  New, Changed, or Refilled Medications  LORazepam (LORazepam 0.5 mg) 0.5 mg, 1 Tablet(s), Oral, q1h, dyspnea or other distress or anxiety, PRN: Other; See comments, 30 Tablet(s), 0 Refill(s)    Instructions:dyspnea or other distress or anxiety  bisacodyl (bisacodyl 10 mg rectal su 10 mg, 1 Supp, Rectal, Daily, PRN: Other; See comments, 10 Supp, 0 Refill(s)    diclofenac topical (diclofenac 1% to 2 g, Topical, bid, PRN: Pain, Mild, 100 g, 0 Refill(s)    hyoscyamine (hyoscyamine 0.125 mg) 0.125 mg, 1 Tablet(s), Oral/Sublingual, q1h, May give 0.125 to 0.25 mg (1 to 2 tablets). HOSPICE PATIENT, PRN: Other; See comments | for excessive oral secretions, 10 Tablet(s), 2 Refill(s)  Instructions:May give 0.125 to 0.25 mg (1 to 2 tablets). HOSPICE PATIENT  morphine (morphine 20 mg/mL oral con 0.25-1mL, Oral, q1h, PRN: Pain, Breakthrough, 30 mL, 0 Refill(s)    ocular lubricant (ocular lubricant p 1 Drop(s), Each Eye, qid, PRN: Dry Eyes, 56 Each, 0 Refill(s)    senna (senna 8.6 mg) 17.2 mg, 2 Tablet(s), Oral, At Bedtime, 30 Tablet(s), 0 Refill(s)      Medications to be Continued  acetaminophen (acetaminophen 325 mg) 650 mg, 2 Tablet(s), Oral, q4h, PRN: as needed for pain    docusate (DOK 100 mg) 100 mg, 1 capsule(s), Oral, bid, For constipation  with plenty of water, 180 capsule(s), 3 Refill(s)  Instructions:For constipationwith plenty of water    Discontinued Medications  albuterol (albuterol 2 mg) 2 mg, 1 Tablet(s), Oral, qid    aluminum hydroxide-magnesium carbona 2 Tablet(s), Oral, AC & Bedtime, PRN: as needed for indigestion    ascorbic acid (Vitamin C) 1 Tablet(s), Oral, Daily    calcium carbonate (Tums 500 mg , che 500 mg, 1 Tablet(s), Oral, Daily, PRN: as needed for dyspepsia    cetirizine (cetirizine 10 mg) 10 mg, 1 Tablet(s), Oral, Daily    doxycycline (doxycycline hyclate 100 100 mg, 1 capsule(s), Oral, bid, 20 capsule(s), 0 Refill(s)    famotidine (Pepcid 20 mg) 20 mg, 1 Tablet(s), Oral, Daily    fexofenadine (fexofenadine 180 mg) 180 mg, 1 Tablet(s), Oral, Daily    fluticasone nasal (fluticasone 50 mc 1 Spray, IntraNasal, Daily    furosemide (furosemide 20 mg) 20 mg, 1 Tablet(s), Oral, Daily, 60 Tablet(s), 6 Refill(s)    hydrocortisone topical (Proctosol-HC See Instructions, apply in a thin film to the anal area and rub in gently and completely daily as needed, 30 g, 2 Refill(s)    lisinopril (lisinopril 20 mg) 20 mg, 1 Tablet(s), Oral, Daily, 90 Tablet(s), 3 Refill(s)    loratadine-pseudoephedrine (Claritin 1 Tablet(s), Oral, q12h, PRN: allergies, 30 Tablet(s), 2 Refill(s)    metoprolol (metoprolol succinate 100 100 mg, 1 Tablet(s), Oral, Daily, 90 Tablet(s), 3 Refill(s)    mometasone nasal (Nasonex 50 mcg/inh 2 Spray, IntraNasal, Daily, PRN: for allergy symptoms    montelukast (Singulair 10 mg) 10 mg, 1 Tablet(s), Oral, qEvening    multivitamin (B-Complex with B-12) 1 Tablet(s), Oral, Daily    omeprazole (omeprazole 20 mg oral de 20 mg, 1 capsule(s), Oral, Daily, 90 capsule(s), 3 Refill(s)    oxybutynin (oxybutynin 5 mg) 5 mg, 1 Tablet(s), Oral, bid, 180 Tablet(s), 3 Refill(s)    oxybutynin (oxybutynin 5 mg) See Instructions, Take 1 tablet by mouth twice daily, 180 Tablet(s), 3 Refill(s)    raNITIdine (raNITIdine 150 mg) 150 mg, 1 Tablet(s), Oral, bid    rivaroxaban (rivaroxaban 20 mg) 20 mg, Oral, w/Supper, 60 Tablet(s), 6 Refill(s)    simethicone (simethicone 125 mg) 125 mg, 1 Tablet(s), Oral, tid PC, PRN: as needed for gas    tamsulosin (tamsulosin 0.4 mg) 0.4 mg, 1 capsule(s), Oral, Daily, for 30 day(s), 30 capsule(s), 3 Refill(s)    terazosin (terazosin 2 mg) 2 mg, 1 capsule(s), Oral, At Bedtime, 0 Refill(s)       Physical Exam at Discharge  Vitals & Measurements  T: 36.8 °C  HR: 80  RR: 16  WT: 70.5 kg  BMI: 25.9      General:  Elderly, Caucasian, male. No acute distress. HEENT: EOMI, PERRL, Mucous membranes dry. Respiratory: Coarse b/l. Normal work of breathing. Poor inspiratory effort. 2 L NC. Cardiovascular:  Irregular rate and normal rhythm. Trace edema of bilateral lower extremities. Gastrointestinal:  Soft, tenderness to right Lower quadrant with noted mass hematoma, ND, +BS. Musculoskeletal:  Moves all extremities; wounds on right foot Integumentary:   No rash noted, weeping LUE, right foot wound see media Neurologic:  Alert, oriented to self and place. Able to state he is in the hospital for "pneumonia". Disoriented to time. Left mouth droop. Speech: Speech impediment which is his baseline.  Time Spent  >35 mins   Follow Up Appointments     N/A  Nursing/Other Orders   Hospice Evaluation and Admission. 02/02/22 13:58:00, Once, 02/02/22 13:58:00, COVID   Mechanical Soft Diet. Start Date/Time 02/03/22 15:50:00 Start Meal Supper 1615 to 1745   Intake and Output. 02/04/22 7:22:19, Continuous Order, q12h. Order comment: Ordered by system rule: ORD_ADD_CHF_TASKS based on indications for congestive heart failure.   Right Heel Suspension (Heel/s suspend, right). 01/21/22 9:28:00, off of the bed with pillow, As Indicated   Left Heel Suspension (Heel/s suspend, left). 01/21/22 9:28:00, off of the bed with pillow, As Indicated   Elevate Head of Bed (Head of Bed Elevated). 01/21/22 12:36:00, Continuous Order, to prevent aspiration; 30 Degrees   Fall Precautions. 01/22/22 2:59:10, Order comment: order placed from nursing documentation CLIN_FALL_RISK   Up to Chair. 01/28/22 8:10:00. Continuous Order, TID w/ meals   Code Status. Code Status Description: DNAR (Do Not Attempt Resuscitation)   Oxygen Instructions. 02/02/22 13:58:00, Routine, Instructions Titrate to comfort. No O2 Saturation Monitoring. Order comment:     Addendum by Dr. on February 04, 2022 13:44:06     I personally saw and evaluated the patient on the result date found in the header of this document.  I independently performed the critical/key portions of the Evaluation and Management service and discussed the management with  nurse practitioner.  I agree with everything documented above with the following exceptions/additions:    no concerns today, he has no pain  sitting upright, no distress  dc to hospice. family supports.