Age: 89.0
Sex: M
Vaccine: COVID19
Symptoms: Toxic encephalopathy, Unresponsive to stimuli
Clinical narrative: Discharge Provider: * Primary Care Physician at Discharge: MD  Admission Date: 10/28/2022 Date of Death: 12/3/2022 COVID Positive Date:  10/28/2022  PRESENTING PROBLEM: Acute respiratory failure with hypoxia [J96.01] Acute hypoxemic respiratory failure [J96.01] COVID-19 [U07.1]   HOSPITAL COURSE: Pt is a 89 yr old M with PMHx of CAD s/p CABG and bioprosthetic AV replacement, chronic diastolic CHF, Atrial fib on warfarin, Hx of CVA, DM II, CKD IIIB, HTN, HPL, BPH, Hx of HSV and dementia (with activated DPOAs) admitted with acute respiratory failure with hypoxia and sepsis in the setting of acute COVID19 PNA and acute on chronic diastolic heart failure with right heart failure. He was started on diuretics and steroids; his son who is his activated DPOA declined use of remdesivir.  Patient improved with rapid resolution of toxic/metabolic encephalopathy.  Hypoxia slowly normalized.  Echo showed preserved EF but with mod decreased RV function with TAPSE of 13mm, RVSP 58mm, and dilated IVC w/ poor collapse consistent w/ fluid overload.  Patient's admission was complicated by a mild AKI secondary to cardiorenal which improved.     Later in the hospital stay - he developed sudden acute on chronic hypoxic respiratory failure.  Patient went from requiring room air to high-flow nasal cannula and subsequently weaned down to 3-4L NC.  Blood cultures grew Corynebacterium - ID was consulted and recommended IV Vancomycin for 6 weeks (from 11/2/22 to 12/13/22). Workup noted left-sided pleural effusion - s/p thoracentesis by IR on 11/4 w/exudative pleural fluid. He was subsequent days IV Lasix. Pulmonary was consulted. CT thorax showed extensive consolidation and groundglass opacities in left lung, as well as pleural effusions. Follow up Chest X rays showed no improvements. Patient remained confused though able to answer basic orientation questions. Pt had intermittent agitation and refusal of care requiring restraints - discontinued on 11/7.   Palliative care followed patient through 11/11 but given goals clear of aggressive care per DPOAs- they signed off. Patient had chest pain episode on 11/14 - refused labs.    The patient had left knee effusion, aspirated earlier in November by Orthopedic service with crystals suggestive of pseudogout. Short court of oral steroids gave partial benefit (permission obtained from ID to give in setting of improving infection.) A course of oral NSAID and colchicine was not effective in removing pain. Intraarticular steroid and aspiration of effusion was performed on 11/21/22. Patient continued to worse despite being on vancomycin.  Has noted to have increased oxygen requirements up to 4 L.  Repeat chest x-ray showing worsening right lung base opacity.  Sputum cultures positive for Gram-negative rods along with Gram-positive cocci.  Cefepime was added. Repeat chest x-ray showed once again large pleural effusion and thoracentesis was repeated on 11/30/22 with 1L bloody fluid removed. Pulm was once again consulted, but the patient refused all treatment options that were suggested and they signed off. Due to patient refusing treatment options and continues to worsen extensive goals of care discussions were done with patient and his DPOA/son about the patient poor prognosis. Per DPOA if patient worsens does not wish for ICU transfer, intubation, or vasopressors. Would be OK with BiPAP/CPAP, but educated that in his current state he would not be a candidate as he would not be able to pull the mask off if needed, son expressed understanding. Patient now on 12/3/22 has become unresponsive with agonal breathing. DPOA again contacted that the patient appears to be actively passing away and stated to keep with the same plan and if he passes away to let him pass away peacefully, but continues to not want to change patient to comfort care. Patient passed away on 12/03/2022 at 1636. Pt.'s son was notified over the phone and all questions and concerns were addressed.