Age: 74.0
Sex: M
Vaccine: COVID19
Symptoms: Human rhinovirus test, Immunodeficiency, Influenza A virus test negative, Influenza B virus test, Influenza virus test negative
Clinical narrative: ED to Hosp-Admission  Discharged 9/15/2021 - 9/18/2021 (3 days).   Last attending ? Treatment team Anemia requiring transfusions  Principal problem   Details of Hospital Stay     Presenting Problem/History of Present Illness/Reason for Admission Chills [R68.83] Weakness [R53.1] Anemia requiring transfusions [D64.9] Acute kidney injury superimposed on CKD (HCC) [N17.9, N18.9]     Hospital Course 1.  Severe sepsis secondary to Covid pneumonia in a immunocompromise patient, patient also has endorgan damage which includes acute renal failure and transaminitis.  Patient has been started on cefepime and doxycycline, Decadron.  Time of discharge I have changed him to cefpodoxime and doxycycline for 2 more days, he will be on dexamethasone 6 mg oral for 5 more days Was  not a candidate for convalescent plasma and remdesivir due to transaminits 2.  Elevated D-dimer: VQ scan negative for pulmonary embolism, ultrasound lower extremity negative for DVT 3.  Acute blood loss anemia related to MDS: Status post blood transfusion, outpatient follow-up with oncology as outpatient. 4.Acute  Renal failure superimposed on CKD stage III: Nephrology has been consulted, holding on Entresto. At the time  of discharge his renal function has improved, needs follow-up as outpatient with his family doctor 5.  Systolic heart failure ejection fraction 30%: Holding on entresto, he could have as needed Lasix 20 mg for shortness of breath, follow-up with heart failure clinic as outpatient 6.  Atrial fibrillation: Continued on home medication 7 coronary artery disease with CABG 2009, peripheral arterial disease with carotid stenting, AAA with endovascular repair: Not on aspirin due to MDS 8.  Diabetes mellitus 2: On glipizide 9.  Hypothyroidism: Continue Synthyroid Physical Exam at Discharge Heart Rate: (!) 55 Resp: 18 BP: 123/57 Temperature: 36.5 °C (97.7 °F) Weight: 96.8 kg (213 lb 6.5 oz)   Physical Exam General : Patient is no acute distress, sitting comfortably HEENT: Atraumatic normocephalic Neck supple CVS: S1-S2 regular rate and rhythm Respiratory: Bilateral equal entry, no wheezing sounds heard Abdomen: Soft nontender bowel sounds present Neurologically: Alert and oriented x3, moving all extremities Extremities no edema ED to Hosp-Admission Discharged   9/20/2021 - 9/27/2021 (7 days)    Last attending ? Treatment team COVID-19  Principal problem    Presenting Problem/History of Present Illness/Reason for Admission Acute on chronic systolic (congestive) heart failure (HCC) [I50.23] Congestive heart failure, unspecified HF chronicity, unspecified heart failure type (HCC) [I50.9] 2019 novel coronavirus disease (COVID-19) [U07.1] Atrial fibrillation with rapid ventricular response (HCC) [I48.91] Diabetes type 2 Severe sepsis due to COVID-19 Cardiogenic versus septic shock Acute renal failure with ATN   Hospital Course Patient was recently hospitalized for Covid infection.  He tested positive on 9/15/2021.  He was discharged on 9/18.  He returned to the emergency department on 9/20/2021 with increased shortness of breath and weakness.  He does have underlying immunocompromised state in the setting of myelodysplastic syndrome, receiving weekly infusions.  He was receiving aggressive care on the medical floor for Covid with steroids and antibiotics, when he decompensated on 9/24/2021.  He was transferred to the ICU.  He was in atrial fibrillation with RVR with a heart rate of 140, blood pressure was 60 over 30s.  He was presumed to be in cardiogenic versus septic shock.  He has multisystem organ failure including heart failure, respiratory failure, kidney failure, and transaminitis.  Initially he was full team.  After discussion with patient and his wife, he is now DNR with short-term intubation only.  He cannot receive remdesivir because of transaminitis.  He cannot receive interleukin-6 because of immunocompromised state.   His ICU course consisted of milrinone drip, Lasix infusion, amiodarone infusion, and brief requirement of norepinephrine.  He has acute renal failure, likely ATN.  He also has transaminitis, acute on chronic congestive heart failure, and worsening Covid pneumonia.  He continues to have hypoxic respiratory failure requiring high flow nasal cannula +100% nonrebreather.  He is essentially requiring a cumulative amount of 75 L of oxygen.   Today he was initially agitated when discussing hospice and states "I will not talk to the death squad". He is insistent on going home, but cannot navigate the decision making process. He does not understand why he can't go home (even though there is no one physically able to care for him at home).  In discussion with his wife, the decision was made to transition him to hospice.  He is uremic and hypoxemic, and likely cannot make high-level decisions.  The patient does agree to go on hospice service.  He was initially adamant about not receiving morphine.  Therefore, we will use hydromorphone infusion as well as scheduled lorazepam and PRN dosing given his significant anxiety.   He will be discharged, and readmitted under inpatient hospice.  It is not feasible at this time for him to go home unfortunately.   Operative Procedures Performed   Physical Exam at Discharge Heart Rate: 60 Resp: (!) 10 BP: (!) 148/59 Temperature: 36.5 °C (97.7 °F) Weight: 96.5 kg (212 lb 11.9 oz)   General: Elderly ill-appearing gentleman sitting upright, appears in mild distress Neck: neck veins are distended Cardiovascular: s1/2, rrr.  Warm extremities with positive pulses Respiratory: Lungs are coarse throughout GI/GU: Abdomen is soft and nontender with positive bowel sounds Musculoskeletal: Trace lower extremity edema Integumentary: Skin is pale warm and dry Neurologic: Patient is alert.  He is oriented to self, place and situation.   He moves all extremities equally. Sensation intact Psychiatric: agitated, blunted affect   Condition at Discharge Discharge Condition: poor