Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Acute respiratory failure, Anaemia of chronic disease, Anion gap, Anticoagulant therapy
Clinical narrative: Deceased (12.27.21); Hospitalized (12.18.21); COVID-19 positive (12.18.21); Fully vaccinated - pfizer x2 d/c summary: Discharge Summary      BRIEF OVERVIEW:     Active Hospital Problems   Diagnosis Date Noted POA ? Mobitz type 1 second degree atrioventricular block 12/27/2021 Unknown ? Oral candidiasis 12/19/2021 Yes ? Acute respiratory failure with hypoxia (HCC) 12/18/2021 Yes ? E. coli UTI 12/18/2021 Yes ? COVID-19 viral pneumonia  12/18/2021 Yes ? Hyperphosphatemia 12/18/2021 Yes ? Acute kidney injury superimposed on chronic kidney disease (HCC) 04/13/2021 Yes ? Anemia of chronic disease 04/13/2021 Yes ? Tobacco dependence 02/09/2017 Yes ? History of CVA (cerebrovascular accident) 08/12/2015 Yes ? Hypertension   Yes ? Hyperlipidemia   Yes ? Class 1 obesity in adult   Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? D-dimer, elevated 12/23/2021 12/25/2021 Unknown ? Community acquired pneumonia of left upper lobe of lung 12/18/2021 12/25/2021 Yes ? Severe sepsis (HCC) 12/18/2021 12/25/2021 Yes ? Type 2 diabetes mellitus with stage 4 chronic kidney disease, with long-term current use of insulin (HCC) 12/22/2020 12/25/2021 Yes    Pre-Existing Active Problems   Diagnosis Date Noted POA ? Hyperparathyroidism (HCC) 04/15/2021 Unknown ? Left homonymous hemianopsia 06/20/2018 Unknown ? PAD (peripheral artery disease) (HCC) 06/12/2017 Unknown ? Microalbuminuria 02/09/2017 Unknown ? Lumbago   Unknown     Date of Death: 12/27/21 Time of Death:  9:09 PM Preliminary Cause of Death: Respiratory failure        Discharge Disposition: Deceased    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: CAP (community acquired pneumonia) due to Chlamydia species  Respiratory failure (HCC)  Acute respiratory failure with hypoxia (HCC)    HOSPITAL COURSE:     Patient was admitted on 12/18/21 for COVID 19 viral pneumonia and acute hypoxic respiratory failure. She was intubated on 12/23/21. Patient was diagnosed with superimpsoed bacterial pneumonia and fluid overload in the setting of COVID 19 pneumonia. Patient was treated with IV antibiotics from 12/18- through 12/27.    Unfortunately in the setting of respiratory failure patient also developed an AKI on her stage 5 kidney disease. Patient was placed on a lasix drip in attempt to creat a fluid negative balance however it became clear to previous IM team that patient would likely need HD or CRRT in order to optimize fluid state.  Doctor discussed with family goals of care on 12/27 and it was known that patient would not want a tracheostomy or HD. At that time it was decided to proceed with comfort care measures and hospice was consulted. Paralytic drip was discontinued at that time. We were unable to terminally extubate patient the afternoon of 12/27 due to paralytics still being active in patient system.  However, later that evening on 12/27 patient became severely bradycardic and went into asystole. Grand daughter was contacted, and it was recommended to remove mechanical ventilator at that point.    TOD 21:09                                            Chief complaint   Shortness of breath   Problem List Principal Problem:   Community acquired pneumonia of left upper lobe of lung Active Problems:   Hypertension   Hyperlipidemia   Class 1 obesity in adult   History of CVA (cerebrovascular accident)   Tobacco dependence   Type 2 diabetes mellitus with stage 4 chronic kidney disease, with long-term current use of insulin (HCC)   Anemia of chronic disease   Chronic kidney disease, stage V (HCC)   Severe sepsis (HCC)   Acute respiratory failure with hypoxia (HCC)   Acute cystitis without hematuria   COVID-19 viral pneumonia    Hyperphosphatemia     Assessment and Plan Medical Decision Making   Hyperphosphatemia Assessment & Plan - Place on low phos diet    COVID-19 viral pneumonia  Assessment & Plan - Decadron 6mg daily for 10 day course  - Onset of symptoms:  7 days ago.  - Mucinex  - Encourage prone positioning and IS  - Supportive medication with PRN cough medication - Vaccination status: vaccinated     Acute cystitis without hematuria Assessment & Plan - Continue ceftriaxone  - Urine culture pending    Acute respiratory failure with hypoxia (HCC) Assessment & Plan - Due to COVID-19 pneumonia with superimposed bacterial infection  - Currently requiring 4L NC - Wean oxygen to maintain sats >90% - Does not wear oxygen at baseline    Severe sepsis (HCC) Assessment & Plan - Due to COVID-19 pneumonia with superimposed bacterial pneumonia and UTI - Received IV fluid resuscitation in Ed, will hold off additional IV fluids in the setting of COVID-19  - Blood cultures pending  - Urine culture pending  - Repeat lactic pending    Chronic kidney disease, stage V (HCC) Assessment & Plan - Acute on CKD V - Mild worsening of renal function  - Baseline GFR 11-14, Baseline Cr: 3.2    Anemia of chronic disease Assessment & Plan - Hgb stable  - Trend with AM labs    Type 2 diabetes mellitus with stage 4 chronic kidney disease, with long-term current use of insulin (HCC) Assessment & Plan - A1C 7.6  - Continue lantus 64 units  - MDSS - BG monitoring AC/HS - Hold oral sitaglitin     Tobacco dependence Assessment & Plan - Encourage nicotine cessation  - Nicotine patches   History of CVA (cerebrovascular accident) Assessment & Plan - Continue plavix and aspirin    Class 1 obesity in adult Assessment & Plan - Increased risk factor for complications in the setting of COVID-19  - Encourage gradual weight loss in the outpatient setting   Hyperlipidemia Assessment & Plan - Continue statin      Hypertension Assessment & Plan - Continue home hydralazine, catapres, norvasc and atenolol  - Hold bumex overnight given severe sepsis and lactic acidosis           Monitor fluid status closely       * Community acquired pneumonia of left upper lobe of lung Assessment & Plan - Continue ceftriaxone and azithromycin  - Urine strep/pneumo pending    Full code  ICU admission Lovenox Qday   History of Present Illness History and physical obtained using telehealth technology with the assistance of the bedside nurse.   a 75 y.o. female  who presents to Hospital. The Patient presents for weakness, shortness of breath, cough for about 1 week. She states that she came in today because symptoms became progressively worse specifically her shortness of breath. She also complains of dysuria for about 3 days. No fevers or chills. + nausea but no vomiting. No diarrhea. No flank pain. She has been vaccinated for COVID back in July. At the time of the interview she is feeling significantly better than when she first presented to the ER. She actually came from another ED. Review of Systems Review of Systems Constitutional:  Positive for activity change, appetite change and fatigue. Negative for chills and fever.  HENT: Positive for rhinorrhea. Negative for congestion.  Eyes: Negative for eye discharge and pain.  Respiratory:  Positive for cough and shortness of breath. Negative for sputum production.   Cardiovascular:  Negative for chest pain and palpitations.  Gastrointestinal:  Positive for nausea. Negative for vomiting, diarrhea and rectal bleeding.  Genitourinary:  Positive for dysuria. Negative for flank pain.  Musculoskeletal:  Negative for joint pain and joint swelling.  Neurological:  Negative for headaches, tremors and numbness/tingling.  Psychiatric/Behavioral:  Negative for depression and anxiety.  Skin:  Negative for itching and rash.      Objective BP (!) 193/37  | Pulse 64  | Temp 36.9 °C (Oral)  | Resp 22  | Ht 1.626 m  | Wt 86.1 kg  | SpO2 94%  | BMI 32.58 kg/m²    Physical Exam Constitutional:      Appearance: She is well-developed.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     General:        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: No respiratory distress.     Breath sounds: No stridor. No wheezing or rales.     Comments: Diminished breath sounds throughout entire lung fields. Abdominal:     General: There is no distension.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: No tenderness.     Right lower leg: No edema.     Left lower leg: No edema.  Lymphadenopathy:     Cervical: No cervical adenopathy.  Skin:    General: Skin is warm and dry.     Findings: No erythema or rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Behavior: Behavior normal.