Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal discomfort, Abdominal pain, Acute kidney injury, Acute respiratory failure, Anion gap
Clinical narrative: Deceased (3.1..22); Hospitalized (2.17.22); COVID-19 positive (2.17.22); Fully vaccinated. J&J x1 d/c summary:  HOSPITAL  Discharged as Deceased Summary   BRIEF OVERVIEW: Discharge Provider: Privacy Primary Care Physician at Discharge: Privacy Admission Date: 2/17/2022   Active Hospital Problems   Diagnosis Date Noted POA ? HCAP (healthcare-associated pneumonia) 03/01/2022 Unknown ? Acute respiratory failure with hypoxia  03/01/2022 Unknown ? COVID-19 02/17/2022 Unknown ? Disseminated histoplasmosis 12/14/2021 Yes ? Long term systemic steroid user 06/05/2019 Yes ? Anxiety associated with depression 04/20/2016 Yes ? Hepatic cirrhosis  01/14/2016 Yes ? Autoimmune hepatitis  05/18/2012  Date of Death: 3/1/22 Time of Death: 10:59 AM Preliminary Cause of Death: Respiratory failure  Discharge Disposition: Deceased   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: COVID-19    HOSPITAL COURSE: ***  Medical Examiner Case Assessment Select Applicable Patient Criteria: Does not meet any of the listed criteria  Discharge Summary (Resident) Hospitalist Cosigned by: Privacy at 3/1/2022  3:41 PM   Attestation signed by Privacy at 3/1/2022  3:41 PM  I personally examined this patient on the day of discharge.  The case was discussed with the Resident.  I have reviewed the DC Summary; it accurately reflects the hospital course and dc recommendations.  35 minutes spent in the depart process.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: COVID-19    HOSPITAL COURSE: 74-year-old female presented with nausea, vomiting, cough.     Admitted for acute hypoxic respiratory failure secondary to COVID-19 and HCAP.  Patient completed 10 day course of steroids for COVID-19, did not receive remdesivir secondary to history of cirrhosis.  Patient completed 5 days of Zosyn for treatment of HCAP.  Despite DVT prophylaxis, patient did suffer complication of acute left small ischemic stroke.  Patient and healthcare provider decided to pursue comfort care measures.  Patient passed on 3/1/2022 at 1059. Family contacted and notified.  2.17.22 H&P:  Attestation signed by Privacy at 2/20/2022  4:27 PM   I have personally interviewed and examined the patient on  2/17/2022 . Management was discussed with (privacy) I agree with the documented findings and plan of care in his/her note.     Brief exam:   Adult woman, sitting up in bed   Bilateral crackles, NC in place  Abdomen is soft, NT, ND     Brief history and medical decision making:   74 y/o woman w/ COVID-19 infection and acute hypoxic respiratory failure, complicated by likely HCAP.  Supplemental oxygen, decadron, Vanc + Zosyn.  CHIEF COMPLAINT: "Knot in Stomach" HISTORY OF PRESENT ILLNESS: 74-year-old female with PMH with disseminated histoplasmosis, autoimmune hepatitis with hepatic cirrhosis, anxiety, hypertension, hyperlipidemia presenting with nausea, vomiting, cough.  Presented from (privacy).  Patient has had numerous recent ED visits, hospitalizations.     Patient initially presented with nausea and vomiting.  Additionally, patient has been having worsening nonproductive cough for which she was started on antibiotics at privacy.  Has been having diarrhea after starting antibiotic.  Discussed that she tested positive for COVID-19, no specific exposure that she is aware of.  Confirms she had J&J COVID vaccination in June.  States she has not been feeling well for some time leading to going to ED and being hospitalized many times.    ED Course:  You hypoxic on presentation, placed on 6 L nasal cannula.  Basic labs obtained.  COVID-19 positive.  Received 1 L bolus for AKI and given dose of Decadron for hypoxia secondary to COVID-19.  Procalcitonin consistent with bacterial infection. Review of Systems Constitutional:  Positive for fatigue. Negative for chills and fever.  HENT: Negative for congestion and rhinorrhea.  Eyes: Negative for pain.  Respiratory:  Positive for cough. Negative for shortness of breath and chest tightness.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Positive for nausea, abdominal pain and diarrhea. Negative for vomiting and blood in stool.  Genitourinary:  Negative for dysuria, frequency and urgency.  Musculoskeletal:  Negative for muscle pain.  Neurological:  Negative for headaches, dizziness and light-headedness.  Psychiatric/Behavioral:  Negative for behavioral problems.  Skin:  Negative for new spots.  OBJECTIVE: BP 154/56  | Pulse 65  | Temp 37.6 °C (Oral)  | Resp 16  | Ht 1.549 m  | Wt 54.3 kg  | SpO2 94%  | BMI 22.62 kg/m²    Physical Exam Constitutional:      Appearance: Normal appearance.  HENT:     Head: Normocephalic and atraumatic.     Nose:     Comments: Nasal cannula in place Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.     Comments: Crackles noted bilaterally, diminished breath sounds at lung bases bilaterally Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: No rash.  Neurological:     Mental Status: She is alert.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:     Comments: Flat affect  ASSESSMENT/PLAN: Acute hypoxic respiratory failure COVID-19 Vaccinated, has not completed booster Presenting symptoms:  Cough, nausea, vomiting. COVID 19 detected by PCR: 2/17. Symptomatic day: 6 CXR with findings of Bilateral pneumonia, greatest in the right upper lobe.  Small bilateral pleural effusions. Received Decadron in ED. Current oxygen saturation 94%, oxygen requirement 2L Severe Respiratory isolation Dexamethasone 6 mg oral daily 1/10 days Unable to use Remdesivir due to cirrhosis Daily labs CBC with differential, CMP, CRP, D-dimer  Daily I/Os Continuous pulse oximetry and telemetry  VTE prophylaxis with Lovenox   HCAP Procal 1.06.  CXR as above. -Blood, sputum cultures -Strep, Legionella -MRSA Screen -Zosyn 4.5g q6h -Vancomycin   Autoimmune hepatitis with cirrhosis      Follows with privacy -LFTs WNL    -Discontinue daily prednisone as patient started on decadron -Continue home mycophenolate  -Disseminated histoplasmosis    -Continue home Posaconazole ( bring to hospital) -Nausea/vomiting, improved-    Improvement noted after bowel movement -continue supportive care and antiemetics -Zofran p.r.n. -Diarrhea      Likely secondary to recent antibiotic use. -continue to monitor      -if persistent or worsening, will obtain stool studies -Hypertension   -continue home Coreg, hydralazine -Mood disorder  -Continue home buspar, ativan, zoloft, trazodone -Overactive bladder    -Vesicare substituted for home Myrbetric   Code:  DNR/DNI Diet:  General Fluids:  PO DVT prophylaxis:  Lovenox