Age: 84.0
Sex: M
Vaccine: COVID19-2
Symptoms: Mobility decreased, Myocardial ischaemia, Pain, Refusal of treatment by patient, Swelling
Clinical narrative: ADMIT DATE: 3/5/2024 to inpatient hospice service  DISCHARGE DATE:   03/12/2024  ADMITTING PHYSICIAN: Dr.  DISCHARGE PHYSICIAN: Dr. ADMISSION DIAGNOSES: Uncontrolled agitation related to ischemic cardiomyopathy Uncontrolled pain related to ischemic cardiomyopathy Coronary artery disease   CONTRIBUTING CO-MORBIDITIES:   Diagnosis   Basal cell carcinoma of skin of other parts of face   Squamous cell carcinoma of skin of face   Squamous cell carcinoma of scalp and skin of neck   Anemia   Atrial fibrillation (HCC)   Heart failure with reduced ejection fraction, NYHA class II (HCC)   Chronic low back pain   Controlled type 2 diabetes mellitus with left eye affected by mild nonproliferative retinopathy and macular edema, with long-term current use of insulin (HCC)   GI bleed   Dyslipidemia   HTN (hypertension)   Lymphedema   PAD (peripheral artery disease) (HCC)   Stage 3a chronic kidney disease (HCC)   Symptomatic bradycardia   VT (ventricular tachycardia) (HCC)   Status post insertion of drug-eluting stent into left anterior descending (LAD) artery for coronary artery disease   Thrombocytopenia (HCC)   Coronary artery disease involving native coronary artery   Restlessness  DISCHARGE DIAGNOSES:same  ADMISSION CONDITION: Poor to guarded  DISCHARGE CONDITION: Deceased  INDICATION FOR ADMISSION: aggressive symptom management of uncontrolled agitation and pain related to severe cardiac ischemia as evidenced by troponin >10,000.  HOSPITAL COURSE: Course of treatment included:  patient presented with recent worsening weakness, dysphagia which worsened after he returned home from recent hospitalization for CAD on March 1st.  Significant other notes that he has not been eating, and has lost about 30# in recent months.  He has been increasingly weak, staying in his chair (does not like feet elevated due to swelling).  On arrival here, his trop was >10K; pt indicated that he did not want any other treatment or diagnostics done.  His sig other, who is his POA, agrees with this and he was therefore admitted to hospice on 03/05/2024.  The hospice service was asked to evaluate the patient for uncontrolled  agitation.  Patient had had multiple doses of valium over the prior 24 hours. He has altered mental status and is not able to verbalize pain well; I suspect that some of his agitation was likely coming from cardiac ischemia, so continuous opioid infusion was started.  This was titrated upward over the following days along with the addition of IV Versed and Haldol to help with agitation.    Pharmacological Interventions: Symptom management included continuous/scheduled IV opiates.  Other treatments included scheduled and PRN benzodiazepines, PRN nebulizers, PRN oxygen for comfort, and scheduled and PRN anticholinergics.  Psycho-social Support: provided by the hospice RN case manager, hospice medical director, and hospice nurse practitioner, with the social worker and pastoral services as needed.  The patient's distressing symptoms were addressed effectively with the above regimen and patient died of his primary illness.  SIGNIFICANT DIAGNOSTIC STUDIES: See H&P  CONSULTS: Wound and Ostomy RN/None.  DISPOSITION: Deceased.