Age: 78.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Blood urea nitrogen/creatinine ratio, Blood urea normal, Brain natriuretic peptide increased, Brain natriuretic peptide normal, C-reactive protein increased
Clinical narrative: 1/13/22  79 yr/o male with history of HTN, DM, HLD, CVA, vascular dementia who presents with cough and shortness of breath. Symptoms worsening over the last several days. Patient was diagnosed with COVID-19 9 days ago. Patient's been on Tessalon Perles but no inhalers or steroids. Patient was noted to have oxygen saturations below 80% on home pulse ox monitor. EMS was called and they reported pulse ox values 88 to 89% on room air. Patient denies chest pain, body aches, fatigue, fever, chills, nausea vomiting or diarrhea. Physical Exam Constitutional:  NAD, well-developed appearance. HENT:  Non-cephalic, atraumatic.  Bilateral external ears normal Eyes:  Extraocular movements intact Cardiovascular:  Normal rate and rhythm, normal heart sounds without murmurs.  Distal pulses normal. Pulmonary:  Pulmonary effort is normal.  No distress.  Normal breath wounds without wheeze, rales, or rhonchi. Abdominal:  Soft.  Non-tender.  Non-distended.  Normal bowel sounds.  No guarding or rebound. Musculoskeletal:  Normal range of motion of the extremities.  Normal ROM of the neck, supple. Skin:  Skin is warm and dry.  No rash. Neurological:  AAOx3.  No focal neurologic deficit.  MAES. Psychiatric:  Speech normal.  Behavior normal.   1/17/22: Summary: Diagnoses:  Acute hypoxic respiratory failure secondary to COVID-pneumonia Acute on chronic diastolic CHF Cardiac arrest Coronary artery disease status post CABG and stent Arterial occlusions of the right and left posterior tibial arteries Hypertension Hyperlipidemia Type 2 diabetes Obesity IBS Anxiety Depression Dementia with agitation Obstructive sleep apnea History of squamous cell cancer  HPI and Hospital Course:   Patient was a 79 yr/o male with PMH of CAD s/p CABG and stent, HTN, HLD, T2DM, obesity, IBS, anxiety, depression, cardiomyopathy, TIA/CVA, cognitive disorder, OSA (non compliant with CPAP), dementia, and squamous cell skin cancer who presented for shortness of breath. Reportedly tested positive for COVID 9-10 days ago. Per EMS, patient's O2 sat were 88-89% on RA and then decreased to 82% when walking. Per chart review he has been vaccinated for covid with Pfizer, not clear on booster.    Patient on admission was noted to be hypoxic and required 2 L nasal cannula. CRP is elevated at 13.9.  Pro-Cal was low. CT chest angiogram neg for PE but showed diffuse bilateral PNA, consistent with Covid 19 PNA.  Suspect acute hypoxic respiratory failure secondary to COVID-19 pneumonia.  Was treated with Decadron, remdesivir, and vitamins c/d and zinc. Since patient was afebrile with no leukocytosis with low procal was monitored off antibiotics due to low suspicion for secondary bacterial pneumonia.  Patient had worsening oxygenation and repeat chest x-ray showed significant interval increase in bilateral airspace disease.  BNP was noted to be mildly elevated and patient was given dose of IV Lasix.  Patient was also significantly agitated that was not able to be redirected which did not improve with Seroquel and patient required IM Geodon.  Per nursing patient was progressively more restless and was removing oxygen.  Reportedly patient went into ventricular tachycardia and later into V. fib with cardiac arrest.  Patient had defibrillation with shock delivered and then was noted to be in PEA. Patient was intubated during code.  Multiple rounds of epi were given during code.  It was discussed with patient daughter his overall poor prognosis due to prolonged arrest.  Patient's daughter decided to withdraw care and patient died on 1/17/2022 at 0128.