Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Acute respiratory failure, Aggression, Agitation, Asthenia
Clinical narrative: Deceased (5.28.22); Hospitalized (5.26.22); COVID-19 positive (5.21.22); Fully vaccinated. -moderna x2 HOSPITALS Discharged as Deceased Summary   BRIEF OVERVIEW: Discharge Provider: medical doctor Primary Care Physician at Discharge: medical doctor Admission Date: 5/26/2022   Active Hospital Problems   Diagnosis Date Noted POA ? Acute kidney injury 05/28/2022 Unknown ? Encephalopathy 05/27/2022 Unknown ? Acute on chronic respiratory failure with hypoxia 05/26/2022 Unknown ? Pneumonia 05/26/2022 Unknown ? Chronic obstructive pulmonary disease 05/26/2022 Unknown ? Narrow complex tachycardia 05/26/2022 Unknown ? Ischemic cardiomyopathy 05/26/2022 Unknown ? Ventricular tachycardia 03/29/2021 Yes ? Intracranial hematoma following injury 02/13/2020 Yes ? Chronic combined systolic and diastolic congestive heart failure 04/19/2016 Yes ? Hypothyroidism 01/15/2016 Yes ? Diabetes mellitus   Discharge Disposition: Deceased  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute on chronic respiratory failure with hypoxia HOSPITAL COURSE: Patient is an 84 y/o M with pmhx of COPD, DMII, HTN, atrial fibrilllation, VT, CHF, CAD & ICM with ICD, hypothyroidism and dementia  who presented on 5/21/22 to outside hospital ED with c/o dyspnea with cough over weeks time, aggravated by exertion. At that time patient had positive COVID 19 test with CXR showing left basilar consolidation with small left effusion. Troponin 0.023, BNP 1030, WBC 7.2 & Lactic 1.8. Admitted to medical center & treated with 3 days of remdezivir, decadron taper & was weaned back to 2L O2. Patient then sent to a sub-acute-rehab (SAR) facility on 5/24/22 where he had a reported sudden change in mental status with confusion, agitation, aggressive with staff. Patient was sedated. Per SAR documentation, concern for dementia prior to COVID 19 infection after discussion with son.   5/26/22 transferred to hospital ICU initiated d/t recurrence of respiratory distress in setting of post-COVID 19 pneumonia with oxygen dependent COPD and suspected fluid overload component. MRSA screen positive. Started on broad-spectrum antibiotics and required HFNC at 100% FIO2. Echo not well visualized, but systolic function appeared mildly reduced. Course complicated by intermittent V tach which self-terminated with no shocks delivered.   Met with family 5/28/2022 and they were all in agreement to transition to comfort care. Patient was pronounced dead at 16:50 on 5/28/2022  5/26/22 H&P:      CHIEF COMPLAINT:     Acute on chronic respiratory failure with hypoxia  ASSESSMENT / PLAN * Acute on chronic respiratory failure with hypoxia Assessment & Plan    Current blood gas is acceptable on 60% high-flow Updated chest x-ray with dense left lower lobe consolidation Plan    Titrate FiO2 as able Marginal candidate for BiPAP given depressed mental mental status Follow serial chest x-rays and fluid status closely   Pneumonia Assessment & Plan     Found to be COVID positive - however available current imaging is atypical for COVID pneumonia Is status post treatment with remdesivir and Decadron as well as CAP with rocephin and zithromax COVID vaccination x2 no booster Plan     Noncontrast chest CT to evaluate pleural versus parenchymal consolidation Zosyn and vancomycin pending culture data Film array/ Panculture Chronic obstructive pulmonary disease Assessment & Plan     Active tobacco abuse up until recently No recent PFTs Reportedly noncompliant with request for home O2 Plan    Bronchodilators as ordered Systemic steroids for acute exacerbation Congestive heart failure Assessment & Plan    Labeled chronic systolic CHF Last EF was 46% ICD is in place Plan is to update echo Monitor fluid status Diabetes mellitus Assessment & Plan      On insulin as an outpatient Glycemic control in place NPO for now Intracranial hematoma following injury Assessment & Plan    Noted following MVA in 2020 Currently with decreased level of consciousness thought to be due to toxic metabolic encephalopathy - noncontrast head CT pending Hypothyroidism     Assessment & Plan On synthroid No recent TSH available - requested SUBJECTIVE:   The patient is an 84-year-old male who originally presented to hospital on 05/21/22 with complaints of weakness.  He was found to have a pneumonia as well as tested positive for COVID-19.  In addition to routine community-acquired pneumonia coverage with antibiotics he was placed on Decadron and remdesivir.  His pulmonary status improved and he was discharged on a 2 L of O2 on 05/24/2022 to subacute rehab.  Shortly after arriving to rehab he had acute mental status change with confusion, agitation.  The day of transfer to our facility described as having marked decrease level responsiveness.   Relevant past medical history includes type 2 diabetes mellitus, chronic obstructive pulmonary disease with recent discontinuation of tobacco for which he is supposed to be on home O2, hypothyroidism, chronic systolic congestive Heart failure last EF 46%, status post ICD placement, history of intracranial hematoma after MVA in 2020 OBJECTIVE: BP 112/88  | Pulse 76  | Temp 36.7 °C (Oral)  | Resp 18  | Ht 1.7 m  | Wt 119.3 kg  | SpO2 (!) 88%  | BMI 41.28 kg/m²  FIO2 (%): 60 % Physical Exam Constitutional:      Comments: Somnolent Arouses to noxious stimuli  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Comments: Prolonged expiratory phase with marked decrease in breath sounds bilaterally Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is disoriented.     Comments: Moving all 4 extremities spontaneously Briefly interactive with noxious stimuli