Age: 92.0
Sex: F
Vaccine: COVID19-2
Symptoms: Hypoxia, Infection, Lactic acidosis, Left ventricular failure, Limb injury
Clinical narrative: Patient is a 93 y.o. female patient of MD with history of aortic stenosis, R UE DVT, chronic leg wounds, DM 2, aortic aneurysm, arthritis, constipation, hypothyroid, HLD, presented to Medical Center with shortness of breath.     Acute respiratory failure with hypoxia, resolved   Likely multifactorial from COVID, bilateral pleural effusions, multiple PE's, decompensated HF. No home O2 requirement Required 5L on admission, now weaned to RA 8/17 Wean to goal >90% Encourage IS/PEP, OOB as able  Diuresis, anticoagulation and covid therapies as outlined   Covid-19 Virus Infection Lactic acidosis  Symptoms present on admission: Cough, shortness of breath Onset of symptoms/date of covid posi  Onset of symptoms/date of covid positive test: 8/11 at ECF Vaccination status: vaccinated Imaging: CT PA showing subsegmental nonocclusive emboli, cardiomegaly, aortic valve calcifications, small pericardial effusion, moderate bilateral pleural effusions, patchy GGO's edema versus pneumonia, compressive atelectasis, Required 5L on admission, weaned to RA 8/17 Medical therapy: remdesivir x5 days and steroids  Anticipated special isolation end date: 8/22 Holding off on further antibiotics for now negative procal and U Ag Per family request, consulted ID.    Acute PE History of RUE DVT Previously diagnosed with a DVT of the right upper extremity Was on Eliquis, however only on 2.5 mg BID Family reports that a vascular specialist thought it was superficial DVT (after a previous IV) hence recommendation for the lower dose of Eliquis CTPA now shows subsegmental PE in setting of Covid and immobility  Initially on hepain gtt pending cardio w/u; transitioned back to Eliquis 8/16 higher dose (discussed w/ pharmacy planning 5mg BID w/o high dose load given age and previous AC) Could consider transition back to lower dose after appropriate PE tx Both events provoked so holding off on any heme c/s or hypercoag w/u   Afib w/ RVR, resolved  New diagnosis. Flipped into RVR 8/15 PM rates 100-130s; improved w/ low dose IV Lopressor  Back in NSR 81/7 Continue Toprol For further episodes of RVR may need amio gtt d/t soft BP. Remains in NSR On AC as below, CHADS2Vasc=5   Severe aortic stenosis Bilateral pleural effusion Acute HFpEF  Takostubo cardiomyopathy CT PA as above, PEs, pericardial effusion, pleural effusions  Suspect troponin elevated 2/2 demand, setting of chronic heart disease and acute respiratory failure  BNP 22k  Echo w/ EF 40% (decrease from previous in 5/2023) as well as regional WMA consistent w/ Takostsubo vs multivessel CAD; again demonstrates severe AS, pHTN. No significant effusion Diuresed w/ IV Lasix, transition to PO 8/17, monitor I/Os  Adding Toprol daily; avoid aggressive afterload reduction given severe AS Cardiology consultation Known severe AS, previously evaluated for TAVR - felt not to be a great candidate; cardio again discussed w/ patient/family electing to hold off on aggressive or invasive evaluation  Repeat Echo in 2-4 weeks Overall long term prognosis is poor   Elevated troponin  Baseline troponin unknown Troponin of 76 on admission; did not get redrawn in appropriate window Likely represents demand ischemia in the setting of hypoxia, PE and infection  EKG shows no acute ischemic ST changes  No plan for ischemic eval at this time    Bilateral lower extremity lymphedema Leg wounds, POA Chronic lower extremity edema and leg wounds, secondary to severe aortic stenosis Cardiology consultation as above. Added diuretic  Wound care following   Sacrum, stage 3 pressure injury, POA Wound care following - instructions added to AVS    Constipation Has not had BM in several days Does have a hx of stercoral ulceration causing significant complications in the past Escalated bowel regimen    QT prolongation  Initial EKG shows a QTc of 524 Given mag in ED Slightly improved on repeat; has bifascicular block Avoid QT prolonging medications when possible   HLD Continue statin    Hypothyroid  Continue synthroid    Goals of care I had a lengthy conversation with patient and family about this 8/16-8/17  Patient struggles with distinction between options; discussed full code vs DNRCCA in detail; patient says multiple times "I would want to just go to sleep and not wake up" however relies on family support for assistance w/ medical decision making  I discussed severe AS, concern for recurrent exacerbations/admissions w/ family by phone; they have good health literacy and understanding of options - will discuss amongst themselves further Remains full code for now May benefit from palliative involvement during future admissions