Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: Respiratory failure, Respiratory syncytial virus test negative, SARS-CoV-2 test positive, Sepsis, Septic shock
Clinical narrative: ED to Hosp-Admission  Discharged   9/15/2021 - 9/19/2021 (4 days) Last attending ? Treatment team Septic shock  Principal problem  Final Summary for Deceased Patient   BRIEF OVERVIEW     Admission Date: 9/15/2021     Discharge Date: 9/20/2021   Final Diagnosis Principal Problem:   Septic shock Active Problems:   Chronic lymphocytic leukemia    Pneumonia of right lower lobe due to infectious organism   Infected laceration   COVID-19 virus infection   Suspected urinary tract infection   Elevated troponin   Acute respiratory failure with hypoxia    Immunocompromised state    Cellulitis     DETAILS OF HOSPITAL STAY   Presenting Problem/History of Present Illness/Reason for Admission Acute pulmonary edema [J81.0] SIRS (systemic inflammatory response syndrome) [R65.10] Septic shock [A41.9, R65.21] Urinary tract infection without hematuria, site unspecified [N39.0] Congestive heart failure, unspecified HF chronicity, unspecified heart failure type [I50.9] COVID-19 [U07.1] Sepsis [A41.9] Pneumonia due to COVID-19 virus [U07.1, J12.82]     Hospital Course: Please send details from H&P intensive care critical care note cardiology was done for neurologist as well as palliative care note   In briefly 85-year-old male history of multiple comorbid condition including CLL with history colon cancer with hemicolectomy admitted with fever chills confusion found to have a right lower lobe pneumonia UTI sepsis septic shock left arm cellulitis. Complicated with septic shock secondary from pneumonia UTI with immunosuppressive state COVID-19 pneumonia patient progressively going downhill even with dopamine drip and continue having persistent hypotension including respiratory failure.  Patient also found to have a right lower extremity DVT patient was initially started Lovenox changed to therapeutic since patient was continued required dopamine unable to discontinue dopamine because of persistent low blood pressure Case discussed with patient family palliative care was consulted and in spite of of all the antibiotic Maxipime and Zithromax and dexamethasone for COVID-19 patient progressively getting downhill palliative care was consulted patient family was involved with the case and since patient prognosis going downhill initially there may DO NOT RESUSCITATE and do not intubation and finally his 2 sons who is the power of attorney decided to comfort care only.  Patient was discontinued dopamine as per policy and was only on oxygen comfort medication was started patient expired approximately September 19 approximately 1830. Because of that respiratory failure secondary from septic shock secondary from multifactorial including pneumonia UTI cellulitis COVID-19 and persistent hypotension in the setting of immunosuppressive patient with CLL colon cancer and lung mass.       Operative Procedures Performed   Treatments: As per hospital policy Procedures: ICU care including dopamine infusion Consults: Intensivist palliative care Pertinent Test Results: CT right lower lobe pneumonia right middle and lower lobe pneumonia       POA   * (Principal) Septic shock Yes       Chronic lymphocytic leukemia Yes       Acute nontraumatic kidney injury Yes       Pneumonia of right lower lobe due to infectious organism Yes       Infected laceration Yes   Overview Signed 9/16/2021  7:31 AM      Infected laceration left wrist with surrounding cellulitis          COVID-19 virus infection Yes       Suspected urinary tract infection Yes       Elevated troponin Yes   Overview Signed 9/16/2021  1:19 AM       Probably due to demand          Acute respiratory failure with hypoxia Yes       Immunocompromised state  Yes   Overview Signed 9/16/2021  1:23 AM       Due to                Medical Problems        Plan: 1.  Sepsis with shock probably due to multifactorial, including right lower lobe pneumonia, infected laceration left wrist with cellulitis, suspected UTI.  The patient will be started on vancomycin, cefepime, and Zithromax.  Patient will be continued on Levophed which has been started in the emergency room.  Respiratory treatment.  Oxygen support.  Continue with BiPAP. 2.  Elevated troponin probably due to demand.  Serial cardiac enzymes.  If the  troponi increase, we will get get an echocardiogram as well as start the patient on IV heparin drip. 3.  Acute respiratory failure with hypoxia.  The family does not want the patient to be intubated.  The agreeable to using BiPAP.  And they also agreeable to admitting the patient to the ICU and use ICU level medications to maintain the blood pressure.  We will continue aggressive management with BiPAP.  Respiratory treatment. 4.  Acute kidney injury.  Gentle IV hydration.  If kidney function continues to discharge in the morning, consider nephrology consultation.   VTE Prophylaxis: SCD                              Lovenox 40mg subcu daily   DNR (Do Not Resuscitate)     History of Present Illness    Chief Complaint Patient presents with ? Fever ? Altered Mental Status     Patient is an 85 y.o. male.   Patient was brought to the emergency room and altered mental status and unable to give any history.  According to the emergency room doctor, the patient was found in respiratory distress with O2 sat of 90% on room air but the patient was very tachypneic.  Patient was also noted to be hypotensive with a blood pressure of 78/68.  Temperature was 101.5.  Patient has history of CLL.  The white count in the emergency room was 94.6.  Hemoglobin was 7.8.  BUN was 41 with a serum creatinine of 2.53.  Chest x-ray revealed bibasilar interstitial prominence.  However, CT scan of the chest shows right lower lobe pneumonia.     Assessment     Review of Systems  Unable to perform ROS: Mental status change