Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Acidosis, Agitation, Anuria, Blood alkaline phosphatase normal, Blood bicarbonate
Clinical narrative: Patient is deceased (11.26.21);  Hospitalized 11.25.21;  COVID-19 positive (11.22.21);  fully vaccinated  Admission Date: 11/25/2021;  Discharge Disposition: Deceased (11.26.21) DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia due to COVID-19 virus [U07.1, J12.82] Septic shock (HCC) [A41.9, R65.21] HOSPITAL COURSE: Patient is a 64-year-old woman past medical history significant for type 2 diabetes, peptic ulcer disease, paroxysmal atrial fibrillation not on home anticoagulation was admitted for septic shock secondary to COVID-19 pneumonia.   Upon arrival to the emergency department, patient was initially hypothermic, tachypneic, hypotensive, hypoxic requiring high-flow nasal cannula and peripheral pressors.  Initial labs were notable for pH of 6.78, creatinine 8.36, potassium 6, bicarb to, ALP 112, lactic acid 16.2.  CXR demonstrated patchy multifocal opacities. Patient was administered 1 L of normal saline, calcium chloride 3 g, 1 amp of bicarb. While awaiting transfer to the medical intensive care unit, patient underwent a fall in her room.  CT head was negative, CT C-spine was notable for severe motion degradation artifact but no evidence of C-spine injury on visualized segments. No injuries noted secondary to fall.  Upon arrival to the medical intensive care unit, patient was significantly encephalopathic and agitated.  Discussion with her son at bedside confirmed wishes for code status of do not resuscitate/DNI as identified in the emergency department by the social worker.  Patient was altered and agitated. She was gasping for air while attempting to get up from bed. She is requiring pressor support, continues to be tachycardic and tachypnic and HFNC @ 50% FiO2. Patient is not producing urine. Fluid status +5.5L since admission. She remained profoundly acidemic with 3 pressors but still had low blood pressures. With her agitation, it will be difficult to place a dialysis catheter without complications or needing to intubate her to place the vascath.  Patient's current condition, treatments, and prognosis was shared with the patient , and family.  Patient continued at this point have worsening septic shock requiring 3 pressors this morning and worsening renal function for which she would be a candidate for renal replacement therapy.  To further pursue renal replacement therapy, patient would likely need to be intubated.  At this point, both son and husband wished to pursue and respect patient's wishes she previously expressed "that she would not want to be on a mechanical ventilator lifelong, or even for short duration if this was only brief while requiring renal replacement therapy." Patient was deemed DNR/DNI per their wishes. After husband arrived to the hospital, patient was transitioned to comfort care and shortly thereafter Dr. was contacted of patient's passing.  Dr's saw the patient at bedside and performed a death examination. Patient was pronounced dead at 5:45 pm likely due to profound shock. I requested for a medical examiner because the patient died within 24 hours of admission and also had a fall while in the emergency department. I spoke with Dr. from the Medical Examiner's office who determined this is not a medical examiner case and does not require autopsy therefore autopsy will not be performed. Ok to release to funeral home.