Age: 68.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Breath sounds, COVID-19, Chest X-ray, Cognitive disorder, Computerised tomogram abdomen normal
Clinical narrative: Patient with 3 Moderna COVID vaccinations who admitted to hospital with complications from COVID and positive COVID PCR.  Patient d/c'd to ALF and then returned 2 days later and subsequently died.  Provider d/c notes from initial and second admission below:  Initial:  "69 YO male with h/o Alzheimer's dementia, hypothyrodism, GERD presenting to the ED for evaluation of AMS.   Patient unable to provide any hx due to his baseline cognitive impairment. Entire hx obtained via chart review, calling co-POAs. Per one POA, patient is able to open eyes and could answer some questions in one word ""on a good day"". Able to tolerate regular diet with assistance though chronically bedbound. Patient currently appearing comfortable though with signs of respiratory distress. Opens eyes to noxious stimuli but unable to answer questions or follow commands.   In the ED, pt is febrile to 102.2F, tachycardic. O2 sat 80% on RA, placed on 3L O2 with improvement though remain tachypneic. Lab work grossly unremearkable other than mildly elevated troponin, with negative delta. COVID positive. CT head, abd/pelvis, CXR nonacute.   During his admission he required ventimask supplemental support but was quickly weaned to room air with dexamethasone and IV remdesevir. His mentation also improved and was at baseline per his caregiver and sister in law. He was discharged back to his AFC in stable condition with strict return precautions. "  ED visit: "0001 69-year-old male presents after being found unresponsive in his AFC home, food and vomitus in the oropharynx, intubated by EMS due to poor oxygen saturation, in the 80% range, not improved after bag-valve-mask.  Intubated without medications.  Continued to remain unresponsive for EMS, arrived intubated, patient had bilateral breath sounds, significant emesis and food material in the oral airway.  Patient febrile on arrival, slightly hypotensive, given a 500 mL fluid bolus.  ET tube exchanged due to significant debris in the tube, chest x-ray confirmed new tube position.  Oxygen saturations in the 90% range on 100% FiO2.  On exam patient unresponsive, no spontaneous eye opening, no spontaneous movement of extremities, lower extremities withdraw to pain bilaterally.  No response to pain to upper extremities.  Broad array of laboratory studies sent, plan to obtain CT scan of head, neck, chest abdomen and pelvis 0035 Spoke with his sister and next of kin, who confirmed his wishes of DNR/DNI and that she would prefer to have him treated palliatively only with no aggressive measures, and comfort care only.  0053 Dr. has specifically discussed terminal extubation with patient's family, which is their wish. Will order palliative pain medication and extubate the patient, stop IV norepinephrine and propofol 0240 Prior to discussion about terminal extubation and comfort care, patient was given a dose of Zosyn, briefly was placed on Levophed to improve his blood pressure, given a dose of Tylenol IV for his fever.  Started on minimal dose of propofol for the sedation.  We were able to reach patient's medical decision maker prior to obtaining CT scan, after having the conversation about terminal extubation and comfort care, will not obtain the CT scan. 0242 All of patient's IV infusions have been stopped, he has been extubated, still with spontaneous respirations, placed on non-rebreather for comfort care, heart rate and oxygen saturation both in the 90s.  Page placed to hospice team to discuss inpatient hospice admission for comfort care 0248 Patient beginning to desaturate, oxygen saturation in the 50% range 0257 Patient has died at 2:55 a.m., patient without a pulse, no heart tones auscultated.  No pupillary response.  Patient's Primary care team and medical examiner notified."