Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Blood creatinine increased, Blood lactic acid, Bradycardia, COVID-19, Cardiac failure
Clinical narrative: being evaluated for COVID-19. Recently receiving treatment for bacterial PNA. On doxycycline at time of admission 10/13/2022. PCT elevated. Unclear when she may have developed symptoms of COVID-19. Rapid COVID negative 10/4; positive at facility 10/12 and positive rapid here 10/13. Reasonable at this time to continue treatment of bacterial PNA now with superimposed COVID-19 viral infection. Problem List: COVID-19 viral infection - Status post 2 of 2 Moderna COVID vaccines, no booster - Positive test at facility 10/12 - Dexamethasone 10/13-present - Remdesivir 10/14 - present. Recent treatment of bacterial pneumonia - Hospitalized 10/4 through 10/7 - Received IV cefepime and azithromycin 10/4-10/7, transitioned to doxycycline for discharge, EOT 10/14/2022 - PCT 1.97 - s/p cefepime and azithromycin x1 10/13 - cefpodoxime 10/14 - present - doxycycline 10/14 - present. Chronic respiratory failure. CHF. COPD - baseline supplemental O2 2L-4L; briefly above baseline requiring 5-6L - currently back to baseline. AKI on CKD - baseline serum creatinine around 1.2 - nephrology seeing patient - eGFR 31; because >30 will proceed with remdesivir and monitor closely. Acute RLE DVT - suspect secondary to COVID-19 - heparin gtt per primary team. Type 2 diabetes mellitus - suspect will experience glycemic excursions in the setting of steroids; management per primary team. Recommendations: - Continue cefpodoxime and doxycycline - Continue steroids - Start remdesivir, plan 5 days however if patient medically cleared for discharge before completion does not need to stay to finish - Strict airborne isolation; plan 10 days at this point, can remove from isolation after 10/22. from death note: admitted to hospitalist service on 10/13 /22 with positive COVID test and hypoxemia after falling and hip fracture about a month prior to admission,  hospital course was complicated by decompensated heart failure and AKI.  Required 4L of nasal canula on admission, increased from 2L of baseline, elevated d dimer, VQ scan was negative. DVT US showed extensive RLE DVT involving the right common femoral, femoral, popliteal, and deep femoral veins. Started on heparin gtt, later transitioned to eliquis for DVT and dexamethasone and remdesivir for COVID infection. Worsening leukocytosis with WBC 29, which could be associated with being on steroids.  Hb decreased from 12 to 7.9 and patient appeared to have worsening RLQ/hip pain. CT ab/pel was done for concern for retroperitoneal vs bleeding in R hip, which showed R gluteus maximus and R vastus lateralis hematomas. Eliquis was held for the morning of discharge due to acute bleed, IR was consulted for possible thrombectomy, deemed not a good candidate for it, and she was being considered for IVC filter placement. General surgery consult was placed, neurovascular checks were ordered for new hematomas and to monitor for limb ischemia. Shortly after lactic acid was drawn, she was noted to have bradycardia and found to be without a pulse. CPR was initiated, and during the code, POA was contacted who requested to cease the CPR and relayed the wish for the patient to be comfortable. ROSC was not achieved end of the code and the patient passed away. Possible causes of death: Probable PE, Severe lactic acidosis and subsequent electrolyte abnormalities, Probable critical limb ischemia, Probable hypovolemic shock 2/2 worsening hematoma. Submitter does not have access to full medical record. If further information is needed, please contact Hospital