Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Acquired diaphragmatic eventration, Alanine aminotransferase normal, Albumin globulin ratio, Angiogram pulmonary abnormal, Anion gap
Clinical narrative: 1/23/22 78 yr/o male hx of prostate cancer on Zytiga with mets to the spine, CAD, D CHF, HTN, HLD, CVA, COPD, triple vaccinated, booster in October, tested positive for COVID 1/16 with recent admission from 1/16-1/19 for hypoxia and COVID-pneumonia, discharged 3 to 4 L nasal cannula, Decadron, here with 2 days of progressively worsening shortness of breath with cough. Patient reports that for the last 2 days has been progressively more short of breath with increased cough, tonight he had a fever 101 at home, with generalized malaise, increased fatigue, decreased p.o. intake, however primarily he is here due to increased difficulty breathing and shortness of breath despite being on 3 to 4 L nasal cannula. Review of Systems  Constitutional: Positive for chills, fatigue and fever.  HENT: Negative.  Negative for congestion.   Respiratory: Positive for cough and shortness of breath.   Cardiovascular: Positive for leg swelling. Negative for chest pain and palpitations.  Gastrointestinal: Negative.  Negative for abdominal pain, diarrhea, nausea and vomiting.  Genitourinary: Negative.  Negative for dysuria.  Musculoskeletal: Negative for myalgias and back pain.  Skin: Negative.  Negative for rash.  Neurological: Positive for weakness and light-headedness. Negative for dizziness, syncope and headaches.  Psychiatric/Behavioral: Negative.  Negative for confusion.  All other systems reviewed and are negative.   1/28/22 Chest Xray  . IMPRESSION:  Increased patchy bilateral airspace opacities representing multifocal COVID-19 pneumonia  78-year-old male with notable past medical history for diastolic CHF, CAD, with CABG, COPD, GERD, hyperlipidemia, hypertension and metastatic prostate cancer on hormonal immunosuppression, skin cancer, and stroke admitted through ED on 1/23 for worsening Covid symptoms after previous positive test and admission on 1/16.    Patient was found to have severe sepsis due to Covid pneumonia and bacteremia based on heart rate greater than 90, elevated C-reactive protein, positive Covid testing, respiratory rate of 30, and positive bacteremia on culture., patient was hospitalized until 1/19 due to hypoxia and was treated with Decadron and remdesivir and sent home with oxygen and Augmentin.    Despite that he is vaccinated along with booster. course likely complicated by chemotherapy for metastatic prostate cancer. Unasyn and azithromycin in ED, discontinued 1/24 Patient admitted to PCU, 1/24 CTA negative for PE but positive for classic Covid pneumonia, previous positive test on 1/16 Previous hospital admission from 1/16-1/19 treated with Decadron and remdesivir, discharged with home oxygen and Augmentin In course received 5 days of Decadron and baricitinib Increasing respiratory support throughout his hospital stay including Vapotherm with nonrebreather and iNO. 1/24 blood culture coag negative staph in 1 bottle, other no growth to date 1/26 blood cultures no growth Likely contaminant, vancomycin DC'd Pro-Cal/Legionella/strep/MRSA/MSSA screen all negative On 1/28: Per chart review, patient expressed to pulmonology that he suspects he is going to die, does not want to be intubated, requesting to go home and be with family.  Pulmonology expressed concerns he would not be able to get the amount of oxygen he was requiring at home.  He is aware requested to made DNR/DNI, code change noted, consult placed for hospice. Current winter storm makes transport tonight extremely difficult.  Family to discuss. On 1/29: Patient confirms that he would like to transition his care to hospice and would eventually like to return home to be with family. Staff reached out to hospice this afternoon, they are planning to set up family meeting to discuss what they offer and address patient and family needs.  We will follow-up.  Pulmonology recommending transfer out of ICU in interim. On 1/30: Patient has been made comfort care, staff attempting to reach hospice representative to alert them of patient's hypoxia overnight, he is unlikely to survive until proposed meeting with family tomorrow, we have waived all visitation restrictions so that family may visit him here at the hospital if he cannot be safely transported home.  Family arrived at 2:15 PM to be with patient.  Patient was taken off of Vapotherm and placed on 100% nonrebreather and allowed privacy with family in room.  Nurse was available and he was made full comfort measures.  Provider was contacted at 4:04 PM that Patient had passed.     Result Value Ref Range   White Blood Count 6.05 4.5 - 11.0 10*3/uL   Red Blood Count 3.45 (L) 4.5 - 5.9 10*6/uL   Hemoglobin 12.4 (L) 13.5 - 17.5 g/dL   Hematocrit 37.0 (L) 41.0 - 53.0 %   Mean Corpuscular Volume 107.2 (H) 80.0 - 100.0 fL   Mean Corpuscular Hemoglobin 35.9 (H) 26.0 - 34.0 pg   Mean Corpuscular HGB Conc 33.5 31.0 - 37.0 g/dL   Red Cell Distribution Width-CV 12.3 12.0 - 16.8 %   Platelet Count 168 140 - 440 10*3/uL   Mean Platelet Volume 10.3 8.4 - 12.4 fL   Diff Type CBC w/Manual Differential (arb'U)   Neutrophils % 82.6 (H) 45 - 80 %   Band Neutrophil% 2.6 0 - 5 %   Lymphocyte % 6.1 (L) 15 - 50 %   Monocyte % 7.0 0 - 15 %   Nucleated RBC % 0 0 /100(WBC)   Absolute Neutrophil Count 5.15 1.5 - 7.5 /uL   Myeloctye % 1.7 (H) 0 %   Neutrophil Abs 5.00 2.0 - 8.8 10*3/uL   Bands-Absolute 0.16 0 - 0.6 10*3/uL   Lymphocyte-Absolute 0.37 (L) 0.7 - 5.5 10*3/uL   Monocyte Absolute 0.42 0.0 - 1.7 10*3/uL   Myelo-Absolute 0.10 (H) 0 10*3/uL   RBC Morphology Comment Normal Normal   Platelet Estimate Adequate Adequate (arb'U) Comprehensive Metabolic Panel(CMP)   Collection Time: 01/23/22 10:23 PM Result Value Ref Range   Sodium 137 136 - 145 mmol/L   Potassium 4.3 3.5 - 5.1 mmol/L   Chloride 103 98 - 107 mmol/L   Carbon Dioxide 24 22 - 29 mmol/L   Anion Gap 10 5 - 13 (arb'U)   Glucose 116 (H) 74 - 99 mg/dL   Blood Urea Nitrogen (BUN) 19 8 - 26 mg/dL   Creatinine-Blood 1.01 0.73 - 1.18 mg/dL   BUN/Creatinine Ratio 18.8 RATIO   Estimated GFR >60 >60 /1.73 m2   Estimated GFR if African-American >60 >60 /1.73 m2   Total Protein 6.1 (L) 6.2 - 8.0 g/dL   Albumin 3.4 3.2 - 4.6 g/dL   Globulin 2.7 1.5 - 4.5 g/dL   Albumin/Globulin Ratio 1.3 1.1 - 2.5 RATIO   Calcium 9.2 8.4 - 10.2 mg/dL   Total Bilirubin 0.5 0.2 - 1.2 mg/dL   AST/SGOT 27 5 - 34 U/L   ALT/SGPT 24 0 - 55 U/L   Alkaline Phosphatase 48 40 - 150 U/L B-Type Natriuretic Peptide   Collection Time: 01/23/22 10:23 PM Result Value Ref Range   B-Type Natriuretic Peptide 44.1 4 - 254 pg/mL Troponin   Collection Time: 01/23/22 10:23 PM Result Value Ref Range   Troponin <0.010 0.000 - 0.034 ng/mL  1/23/22 Chest xray  IMPRESSION: Postsurgical chest with chronic right diaphragmatic elevation. Increased bilateral reticular pulmonary pattern may relate to atypical/viral infection or bronchitis 1/24/22  CT Angiogram Chest For PE  IMPRESSION: 1. No evidence of a pulmonary arterial embolism. 2. Development of a mild to moderate severity pattern of bilateral atypical/viral pneumonia. CO-RADS Category 6. Level of suspicion for pulmonary involvement of COVID-19. Proven. RT-PCR positive for SARS-CoV-2. 3. Thoracic aortic atherosclerosis and coronary arterial disease. 4. Chronic right diaphragmatic elevation and right basilar atelectasis. 5. Hiatal hernia.