Age: 81.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Pain, Patient restraint, Positive airway pressure therapy, Respiratory distress, SARS-CoV-2 test positive
Clinical narrative: 11/23 ED Visit: This 81-year-old female comes in saying she fell in her bathroom 2 days ago and hit the edge of the shower. She states she thinks she was cleaning when she became suddenly dizzy and collapsed. She denies LOC. She is complaining of a headache. She denies any loss of vision or double vision. She has no loss of hearing. She denies any neck pain. She has no back pain. She denies chest pain or shortness of breath. She reports poor appetite as well as nausea and diarrhea. She thinks she has a UTI now because of the diarrhea. She denies any joint or extremity pain. She has no focal numbness tingling or weakness in her extremities.Tested for COVID came back +, sent home.  11/24Back Pain PT is back today. Back Pain      PT is back today because her lower back hurts and she cannot eat due to nausea. Denies emesis.  o Nausea o COVID19 Research  This is a 81-year-old female I saw yesterday and discharge home after a fall. She was diagnosed with a UTI and put on Keflex. She also was diagnosed with covid19. Patient wanted to go home. Prior to discharge her O2 sats were running 90-91% on room air. She returns today because of lower back pain. She states she is continuing to have nausea. She has generalized weakness and body aches. She denies any fevers. She's had no new chest pain or shortness of breath. She denies vomiting or diarrhea. 11/25 1-COVID 19 Pneumonia   2-Acute Hypoxic Resp Failure 11/26 ASSESSMENT/PLAN:  1. Coronavirus disease-19 pneumonia -The patient is currently maintained on remdesivir, Decadron, vitamin C, vitamin D, zinc 2. Acute hypoxic respiratory failure. - on high flow O2 The patient on admission had a COVID testing done, which turned out to be positive and a urine culture also was taken, which showed E coli, which was susceptible to ceftriaxone.  The patient was admitted, was started on Rocephin.  This is day #3 of the Rocephin.  Also, has started the patient yesterday on treatment for COVID including remdesivir, zinc, vitamin C, and Decadron.  The patient is currently maintained on nasal cannula at 4 L and saturating 94%.  When seen, the patient complained of cough and dysuria. Denied any chest pain.  She also has shortness of breath.   11/28 Patient having some respiratory distress and hypoxic. Patient SP02 WAS 81% on NRM 15 LITERS AND 15 LITERS HIGH FLOW NC. Patient is now BIPAP. 11/29 The last dose of dilaudid.  Woke up agitated again, wants bipap off. 02 sat drops when  agitated. HR is also elevated. Able to turn self to sides. Dilaudid was given  And pt went back to sleep. Around 2000 pt woke up, got very agitated,  Tried to removed bipap and was screaming. Was complaining of back pain. diladid was given and pt went back to sleep.  pt decline in medical status & transfer to ICU 0850-0900 Received from 5imc as a rapid response for tachycardia and respiratory distress. Remains on bi pap. Repositioned for comfort. See complex assessments for further data. Will continue close monitoring. 1042-1130 Agitated and pulled out bi pap mask and desaturated, placed on cold high flow oxygen. Bilateral soft wrists restraints applied loosely from patient pulling at lines, tubes and equipment, and for protection from injury.Comfort measures maintained 1220 Palliative NP,  spoke to daughter. Patient made DNR Comfort with consult to Hospice Service. Critical care aware.  Pt expired at 2137. Family at bedside.