Age: 78.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Neurological examination abnormal, Oxygen saturation decreased, Positive airway pressure therapy, SARS-CoV-2 test positive, Ultrasound Doppler normal
Clinical narrative: transferred to hospital on 10/10/2021, Passed away on 10/12/2021 REASON FOR ADMISSION   Stroke    HOSPITAL COURSE Patient is a 79-year-old male admitted to the hospital on 10/10/2021 after he was found to have multiple focal ischemic strokes, mainly a left cerebellar stroke due to left vertebral artery and PICA occlusion.      Past medical history if significant for atrial fibrillation on Xarelto, OSA on CPAP, and diabetes (on metformin).    On 10/4/2021 he developed COVID-19 infection and presented to the ED for evaluation of shortness of breath and weakness.   He was admitted to the medical floor and given supplemental oxygen, remdesivir, and dexamethasone.  Around midnight on 10/10/2021 he became unresponsive and bradycardic with heart rates in the 30s with oxygen desaturation. He was initially placed on BiPAP but required intubation shortly thereafter.   CT/CTA chest was obtained after intubation, negative for acute PE but did show findings consistent with Covid-19 pneumonia.  Around 0200 a head CT was obtained which showed an acute left cerebellar infarct with effacement of the 4th ventricle and hydrocephalus with dilated 3rd ventricle and lateral ventricles.   He was transferred to another hospital on 10/10/2021. Recommended starting barcitinib (JAK inhibitor) for COVID pneumonia. He was started on Lovenox 30 mg subcutaneous b.i.d. for D-dimer greater than 3000.  Lower extremity ultrasound was negative for DVT. Neurology was consulted who recommended a repeat head CT with CTA 12 hours from the initial. CT/CTA at 1500 showed bilateral inferior cerebellar infarcts with an occluded left vertebral artery and left PICA.  There is progressive edema with worse effacement of the 4th ventricle and the prepontine cistern. Given worsening mass effect and brain compression he was transferred to another hospital for management.   His initial neurological exam was poor, although confounded by sedative medications. He was started on mannitol with improvement early in the day on 10/11/2021. Neurosurgery was consulted and evaluated. They discussed neurosurgical options with his family, who conveyed that surgical options would not reverse injury already sustained and therefore not be consistent with his wishes. His neurological exam worsened overnight on 10/11/2021 where he was not following commands in the left hemibody. Despite hydration and careful monitoring he developed acute kidney injury.    Family including wife and three sons were updated via telephone regarding the severity of his strokes. After discussion they agreed that he would not want to live with neurological disability and losing any part of his independence would not be consistent with his wishes. He also had a living will stating that he would not want artifical means prolonging his life if recovery consistent with his wishes was not able to be achieved. Therefore, he was transitioned to comfort care measures after discussion with patients family on 10/12/2021. He passed away peacefully with family at the bedside at 4:44 pm.