Age: 94.0
Sex: M
Vaccine: COVID19
Symptoms: Increased tendency to bruise, International normalised ratio increased, Leukocytosis, Lung hyperinflation, Mean cell volume normal
Clinical narrative: Patient vaccinated 2/17/2021 (first dose 1/28/2021), admitted 8/9/2021, tested positive for COVID 8/9/2021. Infection prevention has determined COVID resolved due to >20 days. Patient is awaiting discharge to facility  Patient admitted and tested positive for COVID on 8/9/21 Date of Clinic Visit or Hospitalization: 8/9/2021 Reason for clinic visit or hospitalization: SOA in setting of COVID infection COVID-19 positive test result: Yes; if Yes, date 8/9/2021 Plans to monitor (include medications if prescribed):dexamethasone 10d course  CC: dyspnea, fatigue, weakness, hospitalized for Acute hypoxis resp failure History Of Present Illness Patient is a 95 y.o. male with a PMH of Afib on Coumadin, recently diagnosed with Covid-19 on 8/4/21 who presents to the ED with worsening SOA, fatigue and weakness. The patient started having symptoms roughly one week ago on Saturday. That day, according to his son, he was confused upon waking, thinking it was Sunday, and then went back to bed and slept for the next 24 hours. The next day his son states he was very weak and had no energy to eat and just wanted to go back to bed. They called his PCP who is also a close friend who advised them to monitor his oxygen. A few days later the patient reported not feeling good and the family checked his oxygen which was <90%. He was taken to Hospital that day and admitted from 8/4/21-8/6/21 and subsequently diagnosed with Covid. He was discharged due to lack of oxygen requirement inpatient. His son states at the time he was too weak to walk from the building to the car and could hardly sit up for any period of time. He had also developed a productive cough with dark brown sputum. He was seen by his PCP two days ago who prescribed azithromycin (he had two tablets yesterday and one today). Then this morning he complained of chest pain and dyspnea. His son checked his oxygen and it was 89% so they called 911 again. The patient states hat he is only comfortable when laying flat on his back which his son also endorses but overall he has difficulty communicating about his symptoms.   The patient states his chest pain is located to the left lower ribs and questionably reproducible. Symptoms overall improved by laying flat, at one point saying it is because he can roll over on different sides, but otherwise no clear aggravating or relieving factors. Currently he rates his pain as a 2-3/10 and states it is improved compared to this morning. Of note, he was previously vaccinated in February 2021. Review of Systems  Constitutional: Positive for unexpected weight change. Negative for chills and fever.  HENT: Positive for congestion. Negative for ear pain and sore throat.        +hard of hearing (has hearing aids)  Eyes: Positive for discharge and itching. Negative for pain and visual disturbance.  Respiratory: Positive for cough (productive).   Cardiovascular: Positive for chest pain. Negative for leg swelling.  Gastrointestinal: Negative for abdominal pain, constipation, diarrhea, nausea and vomiting.  Genitourinary: Negative for dysuria.  Musculoskeletal: Negative for arthralgias.  Skin: Negative for rash and wound.  Neurological: Positive for dizziness. Negative for light-headedness and headaches. Numbness: mornings.  Hematological: Bruises/bleeds easily.  Psychiatric/Behavioral: Negative for confusion.   Patient is a 95 y.o. male    On presentation to the ED he was tachycardic with HR of 112, reportedly hypoxic to 80-85% on RA this morning, now stable with oxygen at 96% on 4L NC. He is afebrile and hemodynamically stable. Initial lab-work notable for leukocytosis (wbc 12.45), elevated D-dimer, CRP, LDH and ferritin and appropriate INR of 3.1. BNP elevated at 5,570. He was given IV Decadron and started on IVF due to recent PO intake. A bedside swallow study was completed which patient did not pass. EKG obtained showing Afib. CXR performed and images personally reviewed - hyperinflation noted as per report with no obvious focal consolidation.    Principal Problem:   Acute respiratory failure with hypoxia   Acute hypoxic respiratory failure with recently diagnosed Covid-19 infection - leukocytosis (wbc 12.45), elevated D-dimer (1.47), CRP (125), LDH (285) and ferritin (appropriate INR of 3.1.  - patient meeting sepsis criteria based on HR>90, RR>20, WBC >12 - mildly elevated procalcitonin (0.4), afebrile - CXR performed and images personally reviewed - hyperinflation noted as per report with no obvious focal consolidation - Covid and viral panel pending, UA ordered and pending  - s/p 1 dose decadron, 1L IVF in the ED  Plan:  -continue decadron 6mg daily; hold remdesivir at this time given age and decreased likelihood of benefit given duration of time since dx and symptom onset -start broad spectrum abx with cefepime, vancomycin and flagyl (given possible aspiration) due to sepsis criteria, elevated procalcitonin and productive cough -continue oxygen supplementation to maintain saturation >92% -delsum and mucinex prn for cough    Atypical chest pain with elevated BNP and D-dimer -labs notable for elevated BNP and D-dimer as above. EKG obtained showing Afib. CXR as above -pain possibly musculoskeletal in nature, son mentioned a strap of some kind located in the area previously. Ddx for pain and elevated BNP also includes cardiomyopathy due to covid-19, cardiac injury/NSTEMI, Afib, pulmonary HTN, PE. No evidence of renal failure based on labs and no hx of CHF or clinical evidence of volume overload on exam or cxr that would explain BNP elevation.  Plan: -troponin ordered and pending -obtain CTPE to further assess for evidence of PE or pneumonia -if negative CT or evidence of PE consider echo for evaluation of CMP or right heart strain  -tylenol prn for pain -telemetry monitoring    Dysphagia in setting of known esophageal diverticulum  - patient failed bedside swallow by RN, has reportedly had swallow study 6 months ago, son is not aware of results, no findings on imaging concerning for aspiration pneumonia at this time Plan: - NPO for now  - start D5 @50ml/hr, fingerstick glucose q6hr   - speech consult placed  - nutrition consulted   Afib on Coumadin  -HR ranging 100s-120s in the room, but generally around 110s. EKG obtained showing Afib -INR 3.1 on admission  -normally on metoprolol 12.5mg daily at night, warfarin 2.5mg nightly; last doses yesterday evening Plan: -continue coumadin, pharmacy to dose -initiate IV medications as needed for rate control  -daily INR    Generalized weakness and poor PO intake -patient's overall health status has been poor since Covid diagnosis with decreased PO intake and weakness -s/p 1L IVF in the ED  Plan: -nutrition consulted as above -PT/OT consult when clinically improved    Hypomagnesemia - Mg 1.8 on admission, replaced in ED - continue to monitor and replace as needed  8/25/2021 No acute complaints overnight, COVID precautions have been lifted as it has been 20 days since his first positive test. Patient and family request that he been discharged to recieve hospice care along with some rehabilitation so that he might be able to  return home with hospice with better quality of life.    Review of Systems: Review of Systems  Constitutional: Negative for activity change, fatigue and fever.  Respiratory: Negative for cough, chest tightness and shortness of breath.    Assessment and Plan: patient is a 95 y.o. male who presented with dyspnea and chest pain found to have likely aspiration pneumonia, now receiving comfort measures only and awaiting transfer to hospice when possible.  Acute hypoxic respiratory failure requiring supplemental oxygen secondary to COVID 19 and aspiration  Aspiration pneumonia/ leucocytosis | aspiration  - Had worsening leukocytosis with elevation in CRP. Chest radiograph showed evidence of possible aspiration in the left lower lung fields on 8/13 with worsening on 8/15. Initially started on empiric antibiotics, however now discontinued as patient is comfort care only.  PLAN:  -supplemental oxygen as needed for comfort, Albuterol HFA inhaler Q4h PRN -morphine 2-4mg IVP q3H prn pain or dyspnea -glycopyrrolate, dextromethorphan, guanfacine PRN   -ordered diet for comfort.   Acute Encephalopathy on Chronic Encephalopathy; Resolved Chronic Sensorineural Hearing Loss  - Likely secondary to acute illness and hospitalization and hearing loss. PLAN:  - Maintain sleep/wake cycle with nightly trazodone  - orienting to day/night, family calls twice daily  - has hearing aids in room    Viral pneumonia secondary to SARS/CoVID-19 pneumonia - Diagnosed 8/4 at Hospital; received 5 days dexamethasone, remdesivir not started given late presentation. Now comfort care only  PLAN:  - patient no longer requires COVID isolation precautions as it has been 20 days since his first positive test, he is no longer considered to be infectious - Acetaminophen 650mg PO Q6h PRN for fever   Atrial Fibrillation | CHADSVasc 2 Home regimen: metoprolol 12.5mg daily at night, warfarin 2.5mg daily; comfort care only at this time  PLAN:  - discontinued home medications    Esophageal diverticulum - Failed bedside swallow by RN. Seen by speech and later cleared to eat on 8/11. Now eating ad lib for comfort   Debility secondary to prolonged hospital stay  - Patient will be discharged to hospice, however would like to eventually return home with hospice care if possible. He requests PT/OT evaluation and discharge to appropriate facility  PLAN:  - PT/OT consulted, awaiting recommendations for rehab    CHRONIC | STABLE | RESOLVED  Proteus UTI- Received 5 days of appropriate antimicrobial therapy  Hypomagnesemia, hypophosphatemia- monitored and replaced, now comfort care only.  Normocytic anemia- hgb 12.1 on admission with MCV of 91   Fluids: PO  Nutrition: Regular diet  DVT prophylaxis -none, comfort care only    Dispo: Hospice once cleared from COVID isolation    8/29/2021 Subjective: No acute events overnight. Reports feeling comfortable. Asks what he has to do to be able to leave the hospital.    I had another long conversation with patient's son this morning about his fathers wishes to be able to return home. Son, tells me that the only way he could come home is if he can eat by himself, sit up and walk. Son tells me that he 'gave his dad these goals.' I told him that his dad is very unlikely to achieve this and that he could be at home with hospice care. Son tells me that home is not an option and he doesn't have the means to help him if he started to pass. I told him that the goal of hospice is to allow a person to pass comfortably at home, he expressed understanding and tells me that even if he did come home, son and his wife are going on vacation from September 12th to Early October and there are no other family members in area able to care for his father. Son requested that we continue to search for a 'facility.'  Assessment and Plan: Patient is a 95 year old male with history of atrial fibrillation and recent COVID admitted for dyspnea and chest pain, now with continued aspiration and decision to be comfort care only. He is comfortable on current level of supplemental oxygen and is awaiting transfer home or to a facility for hospice care.  Viral pneumonia secondary to SARS/CoVID-19 pneumonia: Diagnosed 8/4 at Hospital; Now comfort care only. No longer requires COVID isolation precautions as it has been 20 days since his first positive test