Age: 82.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Laboratory test abnormal, Malaise, Micturition urgency, Pneumonia, Respiratory distress
Clinical narrative: Patient is DECEASED;  hospitalized (1.14.22);  COVID-19 positive (1.14.22); fully vaccinated (no booster) Admission Date: 1/14/2022 Preliminary Cause of Death: Acute hypoxemic respiratory failure due to COVID-19  DETAILS OF HOSPITAL STAY: HISTORY OF PRESENT ILLNESS: Patient  is a 82 y.o. male who presents today with weakness, SOB and diarrhea. There was initially high concern for COVID and wife was also being tested for COVID. Patient did test positive for COVID in the ER today. Per report his quality of life was poor even prior to contracting COVID. He is unable to provider history due to his clinical state. It sounds as though his symptoms started 10 days ago. He has significant work of breathing and rapid decline. He was started on high flow and NRB in the ER and was unable to bring his oxygen higher than high 80s to low 90s. He was also noted to have hyperkalemia, hypernatremia and acute renal failure with Creatinine of 5 up from baseline near 2. ER provider spoke with family and wife felt that patient would not want resuscitative measure and would want comfort care and wife, children and patient siblings all understood this would be end of life and wished to proceed with comfort care which was started in the ER. Social work was consulted and wanted to have patient seen by hospice. Hospice nurse evaluated patient and discussed case with on-call hospice provider who agreed patient was hospice appropriate. He is being started on versed and fentanyl drip for comfort with plan to wean off high flow. Reviewed comfort care with multiple family members at bedside and verified all were in agreement, they had no questions at this time. They requested that medical history be obtained from chart at this time as patient is comfort care. Per family at bedside he has not really been responding for them but will occasionally move though not really following commands.  PRESENTING PROBLEM: Acute respiratory failure with hypoxia  Acute hypoxemic respiratory failure due to COVID-19 Acute renal failure superimposed on stage 3b chronic kidney disease, unspecified acute renal failure type  Pneumonia due to COVID-19 virus   HOSPITAL COURSE:  Acute hypoxemic respiratory failure due to COVID-19  Assessment & Plan Patient has had COVID symptoms for 10 days. He is vaccinated with last dose 3/2021 Presented with worsening SOB and hypoxia.  COVID positive in the ER, likely multifactorial with COVID, elevated BNP and LLL pneumonia on CXR  CXR showing Left lower lobe pneumonia so ? If secondary bacterial source On high flow and NRB in the ER could not get patient above 89% and family did not wish for intubation Family has decided to proceed with comfort care at this time Ativan PRN and morphine drip started in the ER Hospice changing to Fentanyl drip and versed drip with pushes as needed Currently on high flow, wean off to patient and family comfort  Social work consulted, family has decided on SH hospice.  RN evaluated patient and discussed with hospice provider and patient is now hospice. If oxygen making him more agitated can remove Electrolyte abnormality Assessment & Plan Hypernatremia and hyperkalemia likely associated with acute renal failure Family has decided on comfort care at this time The patient was admitted earlier this evening around 18:00 after presenting to the ER a few hours earlier with weakness, shortness of breath, and diarrhea.  He was positive for COVID with symptom onset 10 days prior.  He was in respiratory distress in the ER and was placed on high flow and nonrebreather in the ER with persistent hypoxia.  He also had multiple lab derangements including hyperkalemia, hypernatremia and acute renal failure.  The ER provider discussed the situation with family and they decided on comfort care.  Social work was consulted and  Hospice became involved.  Patient was started on a fentanyl and versed drip for comfort.  He was weaned off of high flow oxygen and died shortly after at 20:15.  Multiple family members were at the bedside, including his wife.   Please see death pronouncement note for exam.