Age: 86.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Mitral valve incompetence, Monocyte percentage decreased, Myelocyte percentage increased, N-terminal prohormone brain natriuretic peptide, Nausea
Clinical narrative: her main complaint on admission to the ER was weakness.  She did receive a Covid vaccine 122 and was concerned that maybe some of the weakness was related to this. She does have a significant low back pain in the emergency room.   She does report feeling chilled intermittently and has had a decreased appetite secondary to nausea.  Hospital Course  86 y/o CF transferred from ER on 1/24/21 where she presented w/ intermittent abdominal discomfort, chills, and nausea - found to have hypotension, lactic acidosis, and concern for GIB w/ weakly positive Hemoccult (on blood thinners). Also head CT showing potential acute superior right frontal lobe infarct in additional to known chronic left frontal lobe infarct. Was given a dose of zosyn, lasix in addition to IVFs prior to transfer. Transferred here for further evaluation. On arrival was hypotensive and required Levophed. Improved. Blood cultures came back w/ 2/2 MRSA. ID consulted. Daptomycin added. Cards consulted and TTE/TEE showed probable vegetation on mitral valve consistent w/ MRSA endocarditis. Had worsening mental status changes with significant combativeness and agitation and worsened left sided weakness (chronic left sided weakness due to prior CVA). Neurology consulted , reviewed outside head CT and agreed w/ acute superior right frontal lobe infarct - feel this was embolic, likely related to endocarditis. Recommended anticoagulation. Dr. felt overall prognosis for a functional recovery is extremely poor.   Unfortunately repeat blood cultures were positive for MRSA again. Source remains elusive. Third set of BCx's from 1/30/21 NGTD.   1/27/21 - She developed slight hypoxia requiring 2-3 liters and cxr showed possible infection vs. edema.  IVF stopped at that time and pulm reconsulted on the morning of 1/28.  She remained on 4L throughout the day on 1/28  and lasix was tried without any improvement.  She subsequently acutely decompensated around 5pm on 1/28  requiring 10+L oxygen prompting transfer back to ICU.  Abx broadened to Teflaro for better pulmonary coverage in addition to her MRSA BSI. Zosyn added on 1/30 due to concerns for potential aspiration.  She has likely developed ARDS possibly from overwhelming infection and continued to be BiPAP dependent requiring significant FiO2.  Pulmonary and ID following and appreciate assistance.  Given that we were not able to wean her FiO2 down palliative care was consulted for ongoing discussion regarding goals of care with suspected ARDS from overwhelming systemic infection.  Unfortunately despite maximal aggressive care she remained BiPAP dependent.  Repeat TTE showed IVC collapse and respiratory status did not improve with diuresis as well as did have slight bump in creatinine.  Palliative care did with ongoing discussions and she was transitioned to DNR/DNI on February 1 per family wishes and ultimately transitioned to comfort care on February 3.  She rapidly declined and ultimately died at 8:45 PM on February 3.  Cause of death was ARDS likely from MRSA bacteremia endocarditis     Lab Results   HEMATOLOGY  WBC: 30.8 (10x3/uL) High (02/03/21 04:24:00)  RBC: 2.69 (10x6/uL) Low (02/03/21 04:24:00)  HGB: 9.4 g/dL Low (02/03/21 04:24:00)  HCT: 29 % Low (02/03/21 04:24:00)  MCV: 102 fL High (02/03/21 04:24:00)  MCH: 32 pg (02/03/21 04:24:00)  MCHC: 31.3 g/dL Low (02/03/21 04:24:00)  RDW: 18.9 % High (02/03/21 04:24:00)  RDW-SD: 70 fL High (02/03/21 04:24:00)  MPV: Not Valid (02/03/21 04:24:00)  Platelet: 83 (10x3/uL) Low (02/03/21 04:24:00)  Neutrophils: 94.9 % High (02/03/21 05:35:00)  Band: 1.3 % (01/31/21 04:03:00)  Lymph: 1.7 % Low (02/03/21 05:35:00)  Reactive Lymphs: 1 % (06/29/19 05:22:00)  Mono: 1.1 % Low (02/03/21 05:35:00)  Eos: 0.1 % (02/03/21 05:35:00)  Baso: 0.2 % (02/03/21 05:35:00)  Immature Neutrophils: 2 % High (02/03/21 05:35:00)  Meta: 0.7 % High (02/01/21 04:16:00)  Myelo: 0.7 % High (02/01/21 04:16:00)  Promyelo: 0.7 % High (01/27/21 05:54:00)  CHEMISTRY  Glucose: 156 mg/dL High (02/03/21 06:56:00)  Sodium: 146 mmol/L High (02/03/21 06:56:00)  Potassium: 4.3 mmol/L (02/03/21 06:56:00)  Chloride: 111 mmol/L High (02/03/21 06:56:00)  CO2: 26 mmol/L (02/03/21 06:56:00)  Anion Gap: 9 mmol/L (02/03/21 06:56:00)  BUN: 78 mg/dL High (02/03/21 06:56:00)  Creatinine: 1.36 mg/dL High (02/03/21 06:56:00)  eGFR Afro-Amer: 41 mL/min Low (02/03/21 06:56:00)  eGFR Non Afro-Amer: 35 mL/min Low (02/03/21 06:56:00)  Calcium: 7.7 mg/dL Low (02/03/21 06:56:00)  Total Protein: 5.3 g/dL Low (02/01/21 04:16:00)  Albumin: 2.1 g/dL Low (02/01/21 04:16:00)  Globulin: 3.2 g/dL (02/01/21 04:16:00)  Total Bilirubin: 1.2 mg/dL (02/01/21 04:16:00)  Alk Phos: 125 U/L (02/01/21 04:16:00)  ALT(SGPT): 22 U/L (02/01/21 04:16:00)  AST(SGOT): 43 U/L High (02/01/21 04:16:00)  Diagnostic Results  (02/03/2021 08:59 CST Chest 1 View) IMPRESSION:  Stable chest demonstrating diffuse pulmonary opacities. [2]  (01/28/2021 17:19 CST Chest 1 View) IMPRESSION:  Increasing pulmonary consolidation and interstitial thickening. [3]  (01/31/2021 14:01 CST CT Abd Pelvis w Contrast) IMPRESSION:   1.  Cardiomegaly with moderate pleural effusions and atelectasis.  Some interstitial thickening and lung infiltrates, left greater than right, could be related to edema and/or pneumonia.  2.  Nonspecific but nonobstructive bowel gas pattern.  3.  Hepatomegaly without focal mass.  Status post cholecystectomy and stomach surgery but no pneumatosis or portal venous gas.  4.  Cystlike lesion in the left kidney is indeterminate.  Ultrasound for further correlation initially although MRI may need to be considered.  5.  Foley catheter in the bladder with some air, could be related to superimposed infection or recent instrumentation.  6.  Trace free fluid in the cul-de-sac but no loculated collection.  7.  Severe atherosclerotic disease. [4]  Interpretation Summary     The left ventricular diastolic diameter is normal (3.8-5.2) cm.  The left ventricular wall thickness is moderately increased (1.3-1.5) cm.  Qualitatively, the left ventricular ejection fraction is 55-60%.  Qualitatively the right ventricular systolic function is mildly decreased.  The interatrial septum is intact with no evidence for an atrial septal defect.  There is mild mitral annular calcification.  There is moderate mitral regurgitation.  There is mild tricuspid regurgitation.  There is bio prosthetic valve at aortic postion.  The bio-prosthetic aortic valve is well-seated.The gradient is normal for the valve.  There is mild pulmonic regurgitation.  There is no pericardial effusion.  Grade II diastolic dysfunction (moderate increase in filling pressure). [5]  Interpretation Summary     A vegetation on the mitral valve cannot be excluded.  Image 11, Frame 29/145 appears to demonstrate an echodensity on the A2/A3 segment that has random chaotic  motion, concern for vlalvular vegetation versus less likely thrombus.  No evidence for abscess on or near the valvular structures.  There is mild to moderate mitral regurgitation.  There is a bioprosthetic aortic valve.  No evidence for vegetations seen on Prosthetic aortic valve  Qualitatively, the left ventricular ejection fraction is 60-65%.  Qualitatively the right ventricular systolic function is normal.  There is no pericardial effusion.  No thrombus is detected in the left atrial appendage. [6]  Procedures and Treatment Provided  Procedure  - Echocardiogram Transesophageal  01/26/21  Comments: TEE   Final Diagnosis and Plan  1.  Acute respiratory distress syndrome likely related to MRSA bloodstream infection     Time of death 8:45 PM on February 3, 2021  2.  Acute hypoxic respiratory failure  3.  Possible MRSA endocarditis  4.  Septic shock secondary to above  5.  History of bioprosthetic aortic valve  6.  Acute right frontal CVA likely embolic  7.  Chronic right frontal CVA  8.  Chronic thrombocytopenia  9.  Delirium  10.  Hypernatremia  11.  Hypokalemia  12.  Paroxysmal atrial fibrillation  13.  Cystic-like lesion left kidney  14.  Acute kidney injury  15.  History of hypertension  16.  Dyslipidemia  17.  Iron deficiency anemia  18.  Obesity  19.  Carotid stenosis status post right carotid endarterectomy  20.  History of left-sided breast cancer status post lumpectomy and radiation       Report of Death  Date/Time of Death:  02/03/21 20:45