Age: 65.0
Sex: M
Vaccine: COVID19
Symptoms: Mental impairment, Myasthenia gravis, Orthostatic hypotension, Oxygen saturation abnormal, Pericardial excision
Clinical narrative: Patient received moderna vaccine on 2/11/21 and 3/11/21. COVID positive on 1/10/22. Presented to ER on 1/17/22 and admitted. One week prior to admission and tested positive for COVID and over the course of the following week developed weakness, orthostasis, syncope.  He came to the emergency department 12, once for syncope and was discharged home and then again for shortness of breath and weakness and was admitted.  Was found to be hypoxic and required 6 L of oxygen to saturate normally.  Was vaccinated with MRA vaccine but not posted.  Was started on Rocephin and doxycycline.  Inflammatory markers followed carefully.  Was started on Decadron and remsdesivir and would complete the course of the latter but be maintained on Decadron secondary to clinical issues as delineated below.  Was followed by pulmonology and Infectious Disease service.  On 01/23/2022 after initially having some improvement had worsening hypoxia and shortness of breath.  Required significant titration of his oxygen to 14 L to saturate normally.  He was transferred to the ICU.  CT scan showed worsening pneumonia.  Secondary to his myasthenia gravis diagnosis and contributions from that issue neurology consult was obtained.  Was requiring BiPAP as well.  Oxygen was titrated to high-flow.  Was started on plasmapheresis on 01/29/2022.  Completed a course of that but did not seem to have any alleviating affect on my senior gravis symptoms.  Was positive for pneumomediastinum on 02/01/2022.  Subsequently found to have pneumothorax 02/09/2022.  Had pneumopericardium as well.  Right chest tube was placed and he was taken urgently to the OR where he underwent median sternotomy, mediastinal exploration, pericardial window placement, chest tube insertions.  Return to the ICU on pressors and hemodynamically unstable.  Had been intubated and was not possible to extubate at that point.  He remained intubated throughout the rest of his hospital stay.  Blood pressure remained labile throughout the rest of his hospital stay he required intermittent pressor.  Was on Dilaudid drip and other pain medications throughout the rest of his hospital stay but not paralyzed secondary to the myasthenia gravis and worries that it would exacerbate.  At that point was on IV Zosyn and vancomycin as well.  Hydrocortisone was up titrated.  Had significant fluid overload and was requiring Lasix.  There were difficulties with breathing over the vent and when his pain medication/sedation would be turned down he would have issues with the synchronizing with the ventilator.  He underwent tracheostomy and PEG tube placement on 02/17/2022.  His mental status never improved.  IVC filter had been placed secondary to difficulty with anticoagulation due to thrombocytopenia and anemia.  There were frequent meetings with family members in particular patient's wife to apprise her of the ongoing issues.  Patient showed no improvement clinically through the end of February.  Continued to have difficulties with weaning from sedation because he would become tachypneic.  Was having intermittent arrhythmia is requiring atropine.  Prognosis remains exceedingly poor in his clinical situation continued to deteriorate and patient's wife was advised as to the multiple issues facing this gentleman.  Decision was made to make patient comfort care on 03/05/2022 and he expired on that date.