Age: 89.0
Sex: F
Vaccine: COVID19-2, FLUA4
Symptoms: Hypotension, Hypoxia, International normalised ratio increased, Lung opacity, Myocardial infarction
Clinical narrative: Discharge Provider:  MD  Primary Care Provider :  FNP    Admission Date: 2/1/2023 Deceased Date:  Date of Death: 2/4/23 Time of Death:  8:08 AM Preliminary Cause of Death: Myocardial infarction (HCC)       Admitting Diagnoses: Pneumonia due to infectious organism   HOSPITAL COURSE: Patient is a 89 y.o. female with past medical history significant for dementia, DVT and pulmonary embolism on Coumadin, hypertension hyperlipidemia, osteoarthritis, iron deficiency anemia, gastroesophageal reflux disease, presenting to an inpatient unit as a transfer from a local Emergency Department where she had presented with chief complaint of increased fatigue, multiple falls, cough, diarrhea, and increased confusion.  Patient lives with her daughter and the falls were happening as she was trying to get off the toilet, no history of head injury.  No history of fever.  It should be noted, that patient is a very poor historian and most of information is obtained from reviewing chart and speaking with the emergency physician   In the emergency department, patient was hypotensive with blood pressure of 84/64 and hypoxic with oxygen saturation of 81% on room air.  Laboratory value with evidence of hypernatremia with sodium 147, hypokalemia with potassium of 3.4, acute kidney injury superimposed on chronic kidney disease stage 3 with BUN of 42, creatinine 1.12, and GFR of 47, liver enzymes elevated with ALT of 42, AST of 66, and alk phosphatase of 111. Initial lactic acid 4.6 decreased to 2.9 after sepsis fluid bolus.  Complete blood count with no evidence of leukocytosis but hematocrit elevated at 48. INR elevated at 6.2 with PT of 56.    COVID-19 PCR detected.  Urinalysis positive for leukocyte esterase, large amount of blood, many bacteria, greater than 180 wbc's, many WBC clumps.  CT head without contrast with no acute intracranial abnormality.  A 3.5 mm nodularity at the left middle cerebral artery trifurcation possible aneurysm.  Two-view chest x-ray with evidence of large hiatal hernia, right lung base opacity concerning for infection.  Left hip x-ray with no evidence of fracture or dislocation, evidence of severe right femoral acetabular joint degenerative changes.   In the emergency department, patient was fluid resuscitated per sepsis guidelines.  Peripheral blood cultures and urine culture were obtained.  Patient was started on IV ceftriaxone and IV doxycycline, and IVF.  She was not hypoxic and with volume resuscitation became hemodynamically stable.  She was confused with was her baseline but remained weak and fairly somnolent despite treatment of her pneumonia.  Since she was not hypoxic she was not given steroids or remdesivir for COVID.  Due to her weakness, SAR or ECF was recommended.  Family asked about hospice care and if they could take her home with hospice.  They did meet with hospice and planned on discharge to home on  2/5.  Unfortunately, the patient developed atrial fibrillation in the setting of a STEMI.  She became hypoxic and since hospice was already being planned no aggressive interventions were carried out.  She was started on a morphine drip and subsequently expired the morning of 2/4.