Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Agitation, Ankle fracture, Anticoagulant therapy, Arthralgia
Clinical narrative: A 77 y.o. female who presented to Hospital on 10/3/2022 from home with complaint of right ankle pain after sliding out of bed 48 hours prior. ED work-up identified a closed fracture of right ankle and she was admitted to the trauma service. COPC was consulted for medical management and preoperative medical clearance.  Her hospital course has been complicated by confusion, electrolyte derangements, COVID-19 pneumonia with hypoxemia, and a declining functional status. General care was assumed on 10/5/2022.  Patient was transitioned to DNR CC   Discharge Diagnosis and Associated Hospital Course   Goals of care Patient's family is electing not to pursue any more aggressive interventions given the several comorbidities that the patient does have -They are set to meet with hospice on 10/22. -Comfort medications have been ordered and other medications have been stopped. Home with hospice.   Traumatic right distal tibia and fibular fracture Presented as as fall from bed with imaging identifying acute comminuted and mildly angulated fractures involving the distal tibia and fibula.   -Status post IM nailing of the tibia and fibula performed 10/4/22 by orthopedic surgery (Dr.).    Acute hypoxemic respiratory failure due to COVID-19 pneumonia Tested positive on 10/8/2022 with URI symptoms believed to have started on 10/2/2022  - Vaccination status: Single vaccine dose June 2022 - CXR from 10/9/2022: infiltrates in the right middle lobe - Received Decadron and Remdesivir IP.   COPD Panlobular emphysema Severe kyphoscoliosis with impaired respiratory mechanics Pulmonary hypertension Tobacco use, active Historical diagnoses with outpatient management that includes albuterol without history of hypoxemia or hypercapnia -Continue to encourage deep breathing and activity out of bed   Acute metabolic encephalopathy Historically present to some capacity since discharge June 2022 and subsequent outpatient treatment for urinary tract infection -Acute changes appear secondary to prolonged hospitalization, hypoxemia, and metabolic derangements -Last assessed via CT brain 10/9/2022 without acute findings -As needed divalproex in place for acute agitation (has not required); quetiapine was last dose 10/12/2022 and has been discontinued -Continue home mirtazapine -Supportive care otherwise   Severe protein malnutrition Failure to thrive Present the context of recurring hospitalizations and significant functional decline with notable weight loss, muscle atrophy and weakness. -Continue to encourage dietary intake along with supplementation -No current plans for enteral feeding -Palliative care following for ongoing GOC discussions. -Family converted to DNRCC on 10/21   Paroxysmal atrial fibrillation (CHA2DS2-VASc 7) Acute chronic diastolic heart failure Essential hypertension Established with Dr. with an outpatient regimen that includes carvedilol, apixaban, and furosemide -Suggestion of pulmonary edema on chest imaging prompted reinstatement of furosemide on 10/14/2022 -Converted into Afib with RVR 10/20.  -Stop Eliquis, holding all medications for atrial fibrillation.  Can consider starting rate control again if patient develops discomfort   Hypernatremia, resolved -Na up to 150. Likely due to poor intake of free water -Na 145 this morning. Improved with D5W. -Holding further fluids due to signs of fluid overload -monitor Na   CAD s/p CABG  Complete heart block No active ACS suspected status post CABG in 1999 and as well as PTCA to the DRCA with patent graft and stent noted on cardiac catheterization in 2019 -Hold all medications due to DNRCC   Type 2 diabetes mellitus with retinopathy without macular edema with steroid-induced hyperglycemia Last A1c is from May 2022 with a range of 6%-6.4% managed with diet off of previously prescribed glipizide -Elevations into the 300s appear dexamethasone therapy related -Stop diabetes treatment.   History of obscure gastrointestinal bleed History includes hospitalization in June 2022 with dark stools, however, upper and lower endoscopy performed at that time was negative without evidence for an obvious source -Capsule endoscopy was recommended along with avoidance of NSAID -Stopping Eliquis due to DNRCC