Age: 54.0
Sex: F
Vaccine: COVID19
Symptoms: Vitamin B12 deficiency
Clinical narrative: Date of Admission  12/25/2021   Date of Discharge  01/08/2022   Reason for Hospitalization   Covid positive 12/19. Increased SOA and fatigue.  Hospital Course       Patient is a 55-year-old female transferred to facility for worsening acute hypoxic respiratory failure secondary to Covid pneumonia.  She has PMH of bipolar disorder and prior tobacco use disorder. Her FiO2 requirements kept increasing on HFNC, she was evaluated and transferred to ICU for further management, intubated 12/31 for respiratory fatigue despite NIV. She has had treatment including dexamethasone, remdesivir, tocilizumab. Abx empiric levofloxacin (12/26-1/4). PF ratio improving with treatment, proning no longer indicated. NG tube placement complicated by Hx of Roux-en-Y; required fluoroscopic placement of NGT. 1/6 overnight patient noted to have significant left sided weakness, CT head showed right frontal intraparenchymal hemorrhage - stroke and neurosurgery teams consulted. Also found to have bilateral PEs on neck CTA. Brain MRI 1/7 AM showed primary intracerebral hemorrhage of right frontotemporal region.   On 1/8 AM, patient was having increased FiO2 requirement, hypotension. Echo bedside showed significant RV dilation consistent with right heart strain presumably from large b/l pulmonary emboli. Patient's family was called in to see patient given worsening clinical condition, and with knowledge that patient would not want trach (the next step in medical management assuming survival of current medical comorbidities), the patient's family (husband and daughter) decided to allow the patient to be made comfortable. Comfort care measures were implemented shortly afterwards with family at bedside. Patient declared deceased at 12:32 PM on 01/08/2022.  Discharge Diagnoses      COVID-19 pneumonia  Acute hypoxic respiratory failure  Acute Respiratory Distress Syndrome, Severe Bilateral mainstem pulmonary emboli Right frontotemporal intraparenchymal hemorrhage  Right frontotemporal intraparenchymal hemorrhage with midline shift  Hypotension secondary to RV overload from pulmonary emboli, bilateral mainstem  Hypotension secondary to sepsis from COVID Adenovirus Pneumonia History of Roux-en-Y gastric bypass B12 deficiency  Pancytopenia  Hyperglycemia   Comfort care measures  Other Diagnoses   Ongoing  BMI 35.0-35.9,adult  Obesity  Historical  Bipolar disease, chronic    Consultants  Neurology    Supportive/Palliative Care    Surgery Neurosurgery   Pending Labs  Blood Culture (Preliminary, InProcess, ordered 01/03/2022, 12:14)   Blood Culture (In Transit, Ordered 01/08/2022, 09:24)   Blood Culture (In Transit, Ordered 01/08/2022, 09:24)   Fungal Culture (Preliminary, InProcess, ordered 12/31/2021, 11:17)   Discharge Disposition  Home, Unable To Determine    Medications  New, Changed, or Refilled Medications  None    Medications to be Continued  None    Discontinued Medications  None  Physical Exam at Discharge  Vitals & Measurements  T: 38.5 °C  TMIN: 37.7 °C  TMAX: 38.5 °C  HR: 134  RR: 32  BP: 108/36  BP: 60/48(Line)  SpO2: 69%  WT: 103.4 kg  BMI: 39.1      General: Nonresponsive  HEENT: Normocephalic, atraumatic.  Resp: No breath sounds heard bilaterally  CV: No heart sounds heart in the aortic, pulmonary, tricuspid or mitral positions. No radial or pedal pulses noted.  GI: Soft, no bowel sounds.  Skin: Warm, dry, and intact skin. No rashes  MSK: No movements noted  Neuro: Nonresponsive, pupils fixed at 3 mm, no cough or gag, no movement of any extremity to pain or command  Time Spent  >60 minutes        Nursing/Other Orders   Hospice Evaluation and Admission. 01/08/22 11:27:00 CST, Once, 01/08/22 11:27:00 CST, COVID-19 | Hypoxia | Bilateral pulmonary embolism | Intraparenchymal hematoma of brain   Adult Tube Feeding, continuous. 01/05/22 14:54:00 CST, Nutren 1.5 - 1.5kcal/mL No Fiber, Goal Rate 60, route Orogastric, how often Daily   Intake and Output. 12/27/21 18:18:00 CST, Continuous Order   Activity, Prone Position (Position, Prone). Start Date/Time: 12/31/21 16:53:00 CST, Special Instructions Please prone patient for 16 hours then unprone for 8 hours   Elevate Head of Bed (Head of Bed Elevated). 01/01/22 9:10:00 CST, Continuous Order, to prevent aspiration; 30 Degrees   Fall Precautions. 01/07/22 3:29:00 CST. Order comment: order placed from nursing documentation CLIN_FALL_RISK   Activity As Tolerated. 12/25/21 23:18:00 CST, Continuous Order   Activity As Tolerated. 12/27/21 18:18:00 CST, Continuous Order   Code Status. Code Status Description: DNAR (Do Not Attempt Resuscitation)   Oxygen Instructions. 01/08/22 11:27:00 CST, Routine, Instructions Titrate to comfort. No O2 Saturation Monitoring. Order comment:     Addendum by MD on January 09, 2022 07:11:29 CST (Verified)    ADDENDUM: I personally saw and evaluated the patient on the result date found in the header of this document. I independantly performed the critical/key components of the E/M service and discussed the management with the author of this document. I review the history, physical, relevant labs, medications, flow sheets, imaging studies, microbiology data and ventilator data (if applicable). I agree with everything documented above with the following exceptions/additions: none