Age: 73.0
Sex: M
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Interstitial lung disease, Lung opacity, Malaise, Oxygen saturation decreased, Pancytopenia
Clinical narrative: Deceased.  Date of Death: 8/11/21 Time of Death:  4:29 PM Preliminary Cause of Death: Respiratory failure with hypoxia        Discharge Disposition: Deceased   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia of both lungs due to infectious organism, unspecified part of lung [J18.9] Acute hypoxemic respiratory failure [J96.01]  a 73 year old male with PMH significant for follicular lymphoma, squamous cell carcinoma of face, recent COVID-19 pneumonia, pulmonary fibrosis, DVT hx s/p IVC filter on warfarin, HTN, hypothyroidism, who presented to the ED on 8/1 for evaluation following a syncopal episode, dyspnea on exertion and cough.  Patient recent COVID-19 infection 6/15/21.  Had remdesivir, steroids and antibiotic therapy, followed by pulm. He was placed on dexamethasone with taper 7/21.  Started on Augmentin on 7/30.  He had the syncopal episode on 8/1 and was found down by his wife.  Negative CT after fall. Had desaturation to 83% in the emergency department. Started on vanc/zosyn. MRSA screen negative and vanc d/c'ed. CT chest in the emergency department showed no evidence of pulmonary embolism, did show prefer ground-glass infiltrates possible COVID-19 infection, also underlying interstitial lung disease.  Pulmonology was consulted. He tested positive for COVID on 08/03/2021. ID was consulted. Thought to be new acute COVID infection rather than viral shedding. Started on dexamethasone 6 on 8/2.  Received tocilizumab on 8/4. Due to worsening respiratory status, patient was transferred to ICU on 8/7.  He was initially DNI. After conversation with patient and family on 8/8, he decided to be full code and pursue intubation. He was intubated on 8/8 and underwent bronch. Vancomycin was added. On 8/9 bactrim was started for empiric PJP treatment and zosyn was changed to meropenem for broader coverage. Patient developed DIC and was treated supportively with transfusions.   Due to worsening respiratory status and poor prognosis, family decided to make patient DNR on 8/10. Decision was made to make patient comfort care on 8/11. Paralytics were held at 2:15 pm. Patient was terminally extubated at 3:49pm with comfort measures. Time of death 4:29pm.    a 73 year old male with PMH significant for follicular lymphoma, squamous cell carcinoma of face, recent COVID-19 pneumonia, pulmonary fibrosis, DVT hx s/p IVC filter on warfarin, HTN, hypothyroidism, who was admitted on 8/1 for management of AHRF 2/2 repeat COVID-19 pneumonia.    #Acute hypoxic respiratory failure #COVID-19 infection #idiopathic pulmonary fibrosis - AHRF etiology COVID vs ILD flare vs bacterial infection. Unlikely CHF exacerbation given echo with EF 62%. - pt volume up which may be contributing to respiratory status - possibility of PE. Known DVT in July, on warfarin. Will treat dvt with heparin which also treats possible PE.  - d-dimer >35,000 since 8/5 - on 3 L O2 baseline - Recent covid infection on 6/15. Thought to be acute reinfection. - s/p tocuilizumab on 8/4 - diurese as needed to achieve net negative 1-2 L /24 hours - IV lasix 40 mg today - increase to decadron 6 mg BID   #superimposed bacterial pna - CXR on 8/1 suggestive of bacterial pna - started on vanc/zosyn in ED - vanc d/c'ed after MRSA screen negative - continue zosyn (first dose 8/2)  - given leukopenia and steroid use, consider addition bactrim for PCP prophylaxis. Will discuss with ID.    #pancytopenia - likely related pt's prior chemo treatments - transfuse for hgb < 7, plts < 10