Age: 88.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Chest X-ray abnormal, Communication disorder, Computerised tomogram head normal, Computerised tomogram thorax abnormal, Confusional state
Clinical narrative: 10/11/21:  arrived to ER from assisted living with c/o fever and cough with known COVID positive X1 week.  94% RA, HR 63, RR 17, 151/86, T max 100.4 F.  Trop 0.165, BNP 2000, INR 1.15, CRP 15.1, NA 134, K 3.0, Ca 7.9, d-dimer 319, WBC 3.6.  CXR mild right sided atelectasis/infiltrates.  Given casirivimab-imdevimab in ER.  Admitted to telemetry for mild COVID PNA and NSTEMI type II demand ischemia.  Started on IV ceftriaxone, IV doxycycline, decadrong, Lovenox, and vitamin cocktail. 10/12/21:  Echo shows new decreased EF 40-45% with new onset grade 2 diastolic dysfunction and right ventricular systolic dysfunction compared to echo 6/2/21.  On 3L NC sat 92% CRP 18.5 troponin 0.108.  ABG 7.52/31.6/114/26.1/BE 4 on 2LNC 10/14/21:  Increased oxygen to 6L NC sat 88%.  CXR concerning for bacterial pneumonia superimposed onto progressing COVID PNA.  Started on remdesivir, added IV vanco.  CRP 5.6, WBC 11.9. 10/15/21:  On NRBM to sat 96% increased SOB.  ABG 7.509/35/1/59/27.9/BE 4.7 sat 92% on NRBM.  MRSA screen positive.  Flagyl added.  Code discussion decided DNR/DNI with trial BiPAP.  Patient becoming more confused/disoriented, aggitated, frightened and not tolerating proning. 10/16/21:  Progressive confusion/combative on 12L venti mask with desats to 70% when removed by patient.  Restraints required for patient safety. 10/17/21:  new large hematoma to left gluteal area.  HH drop 6.2/19.3 PRBC transfused, lovenox held.  Taper decadrone for steroid induced encephalopathy.  WBC 17.2, CRP 6.8. 10/19/21:  Venti mask 15L with continued confusion/combative.  1:1 sitter for safety. 10/24/21:  Lovenox resumed - hematoma stable.  Improved mentation AOX2-3.  Sitter no longer needed.  6L Nc sat 93%. 10/28/21:  2L NC sat 95%.  All antibiotics completed.  Stable for discharge to skilled nursing facility for short term rehab.  Unable to transfer out patient due to continued positive COVID test status.  Placed in skilled level of care pending negative test for transfer to SNF. 10/31/21:  new onset RUE edema.  Dopplar shows positive DVT.  Lovenox changed to Eliquis. 11/4/21:  AM  Increased need for oxygen to 5L NC sat 93%.  Wheezing and SOB with any activity.  Returned to acute level of care. 11/4/21: @ 2102 Rapid response sat 86% on 5L NC, dyspnic with accessory muscle use, RR 30s, +2 BLE pitting edema.  Placed on NRBM.  ABG 7.497/42.6/261/33/8.9 sat 100% on NRBM.  CXR shows fluid volume overload and increasing infiltrates.  IV Lasix X2.  BNP 2040, WBC 7.2, CRP 5.2, d-dimer 523.  Unable to scan for possible PE due to patient reaction to contrast dye.  Placed on BiPAP 12/6 FiO2 60% at night for two days. 11/7/21:  15L via HFNC sat 94%.  Positive for UTI psuedomonus.  Started on cefepime. 11/10/21:  14L HFNC sat 87%.  Dyspnea at rest.  Started on short course steroids. 11/11/21:  Labored breathing.  ABG 7.45/44.1/63/30.2/BE 6 sat 91% on NRBM.  CT chest shows progressive pulmonary infiltrates and new bilateral pleural effusions.  Started on Vanco. 11/12/21:  Increased confusion and disorientation.  NRBM with any activity for labored breathing. 11/13/21:  Confusion and inability to communicate clearly.  Stat head CT negative.  Resolved without intervention within 24 hours. 11/14/21:  Right sided thoracentesis removed 550 ml with small apical pneumothorax which self resolved by next day.  Decreased to 10 L via HFNC to sat >92% 11/16/21:  6L NC sat 94% improved mentation 11/23/21:  1L NC with activity to maintain sat >90%.  Mentation improved.  Stable for discharge to skilled nursing facility for short term rehab.  Patient discharged in PM.