Age: 77.0
Sex: F
Vaccine: COVID19-2
Symptoms: Atrial fibrillation, Blood creatinine increased, Blood gases, Blood lactic acid, Blood pH normal
Clinical narrative: Discharge Provider: MD Primary Care Physician at Discharge:  MD Admission Date: 9/28/2022  PRESENTING PROBLEM: Fall, initial encounter [W19.XXXA] Acute hypoxemic respiratory failure (HCC) [J96.01] Acute hypoxemic respiratory failure due to COVID-19 (HCC) [U07.1, J96.01] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 77 y.o. female with a PMH of limited scleroderma with CREST syndrome, pulmonary hypertension, restrictive lung disease, AFib on Xarelto, combined systolic and diastolic heart failure who presented to the ED 9/28/22 with altered mental status and weakness. She had experienced a ground level unwitnessed fall 9/27/22 and was evaluated at ED and was able to retturn ot home where she was living with her spouse. While advanced imaging did not demonstrate acute pathology, family reports patient became progressively weak and tired with altered mentation. They decided to present to ED as she was lethargic and no longer able to ambulate.    Vital signs notable for BP 99/62, HR 150, SpO2 77% and temp 38.7 C. A nonrebreather was placed with SpO2's remaining in the 70% range. Was then escalated to HFNC at 50 L/min which improved oxygenation to 80's. SpO2 increased to max of 88%. ABG revealed pH of 7.4 CO2 of 34 and PO2 of 61. Patient was not considered a candidate for bipap due to mental status. Labs notable for CMP with BUN 32, creatinine 1.49, AST 55, troponin 87 with delta -17 on repeat, BNP 29,942, TSH 5.75, lactic acid 4.3 with interval improvement to 2.7, positive COVID-PCR. Chest XR demonstrated small amount of patchy atelectasis or pneumonitis in the RUL. CT head and neck w/o contrast without acute abnormality. CT cervical, thorax and lumbar spine without acute findings. CT t/a/p demonstrates no acute abnormality in the chest, abdomen or pelvis but demonstrated biatrial enlargement and bronchitis. EKG demonstrated Afib with RVR which was treated with one dose of metoprolol with improved heart rate and blood pressure. Patient was given 2 L of fluids and started on Zosyn due to concern for infectious etiology. She was also given a dose of decadron. With the development of these findings and worsening clinical condition of the patient, family decided to pursue comfort care and avoid invasive diagnostic testing. Patient was admitted for acute hypoxic respiratory failure with the goal of arranging home hospice services.    Shortly after arriving to the admitting floor,  was transitioned to non-rebreather for comfort overnight. The morning of 9/29, patient's family wished to further transition to nasal cannula to improve comfort. Palliative care was consulted as well as chaplain services. Palliative care team assisted with connecting with home with hopes of having hospice services arranged to be able to take patient home in 1-2 days. While logistics were being arranged, patient's comfort continued to be optimized. Multiple family members were able to visit 9/29/22. Family went home the evening of 9/29 and patient passed away the morning of 9/30/22.    Date of Death: 9/30/22 Time of Death:  7:01 AM Preliminary Cause of Death: Respiratory failure with hypoxia (HCC)