Age: 78.0
Sex: M
Vaccine: COVID19, FLUC4, COVID19
Symptoms: COVID-19, Cellulitis, Chronic kidney disease, Computerised tomogram abdomen abnormal, Computerised tomogram thorax abnormal
Clinical narrative: BRIEF OVERVIEW: Discharge Provider: DO Primary Care Physician at Discharge: DO  Admission Date: 10/10/2022 Date of Death: 11/11/22 COVID positive Date 11/8/2022 HOSPITAL COURSE: A 79 yo male with PMH of CKD 3b, PAD, NIDDM2, diabetic ulcer of right foot, permanent atrial fib, essential HTN and GERD who presented to the ED due to pain when ambulating on his known chronic diabetic right foot ulcer for which he follows with the wound clinic. XR of the right foot without acute fracture or evidence of osteo with blood work demonstrating leukocytosis and elevated CRP. He was admitted to the medicine service for right foot diabetic ulcer associated with cellulitis. The patient had a long and complex admission. In brief, regarding Diabetic Ulcer or Right Midfoot with PAD, the patient was initially treated with IV Unasyn and wound care was consulted. Superficial cultures were obtained and noted to have grown pseudomonas and antibiotic was changed to Cefepime. MRI was obtained without evidence of osteo or drainable fluid collection, with possible cellulitis. He was continued on Cefepime primarily due to persistent leukocytosis and elevated CRP but wound clinically appeared not be grossly infected and therefore Cefepime was discontinued after 3 days. ABI was obtained which was non-diagnostic for RLE and with 75% stenosis of left posterior tibial artery. Wound recommended CTA abdomen/pelvis with runoff for better visualization of LLE, however due to development of AKI this was postponed. Regarding Rhinovirus-Enterovirus infection and acute hypoxemic respiratory failure; the patient reported dyspnea and cough that had been ongoing for a few weeks prior to presentation and was noted to have tachypnea. Due to persistent leukocytosis, CT thorax/abd/pelvis without contrast was ordered (lack of contrast due to AKI), which demonstrated known right renal mass, along with tree-in-bud opacity in the RUL suggestive of infective bronchiolitis and thyroid mass. Due to persistent leukocytosis and elevated pro-calcitonin (albeit in setting of AKI), patient was restarted on antibiotics. Course was complicated by bilateral pleural effusions.    Other complications during his hospital stay included anemia, for which GI were consulted, egd 10/22 with hiatal hernia, antral erythema not consistent with GAVE. Vitamin K was given for a supratherapeutic inr early in hospital course with no further bleeding complications, however he did develop a hemoglobin of 6.9 on 11/7, for which no transfusion was given due to goals of care.    Regarding AKI on CKD 4 (not 3b as per prior notes), Nephrology were consulted, foley placed for bladder outlet obstruction and he was treated for prerenal causes as well.    Eventually the patient became more and more malnourished, less and less responsive, as well as declining care at times. He was found not to have adequate medical decision making capacity by two physicians, with inability to explain rationale for choices or to retain information, so medical power of attorney was activated.  Hospice and Palliative services were contacted. Family / Powers of attorney decided on Comfort Care measures and to discharge to facility with hospice. Comfort care was started on 11/7 after discussion with power of attorney. Feeding tube was removed by their request.   Patient incidentally tested positive for COVID on day of planned discharge to hospice facility. He therefore stayed admitted under GIP. He passed away with family at bedside 11/11.