Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Asthenia, Atrial fibrillation, Bronchial obstruction, COVID-19
Clinical narrative: Discharge Physician:  MD Primary Care Physician:  MD Date of Admission: 11/28/2022 Discharge Date: 12/6/2022 COVID positive Date 11/28/2022 PRESENTING PROBLEM: Lung mass  Acute respiratory failure with hypoxia (HCC)  COVID  Pneumonia due to COVID-19 virus  Acute hypoxemic respiratory failure (HCC)    HOSPITAL COURSE: Patient is an 87-year-old male with a past medical history of coronary artery disease status post CABG, melanoma, squamous cell cancer of the head neck, paroxysmal atrial fibrillation not anticoagulated presenting for weakness and shortness of breath.  He has had a 10 lb weight loss, cough, decreased energy.  He was found to be positive for COVID.  CT scan was performed on his chest which revealed a right hilar mass encasing the right main bronchus with partial occlusion of the proximal right lower lobe bronchus and significant narrowing of the right upper lobe bronchus which was suspicious for a primary bronchogenic malignancy like small cell lung cancer.  Patient was started on Decadron remdesivir for COVID 19 infection.  Overnight and into the early morning patient had an episode of desaturation requiring initially high-flow nasal cannula with non-rebreather over top.  With this intervention he was still only saturating in the mid to high 80s and was confused.  Patient was brought to the intensive care unit and placed on BiPAP.  Repeat chest x-ray showed developing pneumonia in the right lower lobe, so he was placed on broad-spectrum antibiotics and MRSA nasal PCR was performed which ended up being negative.  Extensive discussion was had with the daughter who then called the family meeting.  At that point patient had improved in his mentation and was able to participate in the meeting.  Patient decided that he wanted to speak with Hematology Oncology about the possibilities of the cancer.  Dr. consulted and recommended the patient improved from his current infections before discussing intervention and biopsy.  He also discussed with patient the unlikely could you be able to tolerate chemotherapy.  Dr. stated that hospice would be appropriate and any time.  Patient did improve during the day on 11/30/2022 and was weaned from BiPAP to high-flow nasal cannula with improving mentation and acceptable saturations.  During the course of the day on 11/30/2022 patient was given a dose of IV Lopressor x1 for atrial fibrillation with rapid ventricular response.  That did improve his rate but caused some hypotension.   Over the course next several days the patient did improve significantly.  He was able to be weaned down to room air during the day, he did still require 2 L at night.  Patient was found to be significantly orthostatic and had a near syncopal event while working with therapy.  He has also noted to initially have an improvement in his hyponatremia and then also worsened again.  Discussions with family were ongoing in regards to discharge planning.  They have opting to take him home with hired caregivers.   There were also multiple ongoing discussions with family regarding the patient's underlying cancer.  They are aware that he likely will not tolerate treatment.  Patient himself is hesitant to make himself hospice without a known diagnosis.   Family discussion with hospice on 12/6/2022. Family and patient decided to go home with home hospice.    Electrolytes were monitored and repleted throughout the admission. Patient clinically improved and hemodynamically stable for discharge.  Discussed plan of care discharge with patient including outpatient follow-up PCP within 7 days. Patient voiced understanding was agreeable with plan of care discharge.