Age: 84.0
Sex: F
Vaccine: COVID19
Symptoms: Agonal respiration, Aspiration, Asthenia, Blood fibrinogen increased, C-reactive protein increased
Clinical narrative: Adverse event note: Per web report received stating the patient presented on 7/23/2022 with generalized weakness. Patient with close exposure to COVID-19, her husband was recently positive. Vague symptom onset, approximately 7/21/2022 which included generalized fatigue/weakness, cough, shortness of breath worse with exertion, headache. PCR on admission 7/23 positive. ER work-up revealing elevated CRP, fibrinogen, D-dimer. Difficulty with IV access unable to obtain CTA chest, nuclear medicine lung scan and obtained with intermediate probability PE. Patient had been on Eliquis previously without tachycardia and maintaining room air oxygen saturations. ID consulted for management given COVID-19.  Patient stated improvement but reports ongoing dry cough and some fatigue. Denies fever/chills, chest pain, abdominal pain, nausea, vomiting, diarrhea, rash, joint pai n. Denies recent travel. Vaccinated against COVID-19 with Pfizer x3, last immunization 11/2021  Per report, this patient was hemo-dynamically stable and saturating well on room air. Patient was admitted given acute viral infection and weakness. The patient had a hospital course of 11 days. Her initial hospitalization focused on conservative management of COVID-19 infection. Patient had no indication for specific treatment, she was supported and remained on room air. However, she was weak and worked with PT/OT. Therapy sessions were notably limited by patient's subjective dizziness. Orthostatic vitals revealed severe and ongoing orthostatic hypotension. Patient noted to be on both metoprolol and diltiazem, and per note, numerous adjustments made to assist with symptoms. Electrophysiologist was contacted as well for support. Despite adjustments to patient's AV nodal agents, her orthostasis persisted. She was trialed on increased salt tabs, midodrine, and Florinef at different times. Despite these interventions, her symptoms and orthostasis persisted. Per note, her chronic dysphagia worsened throughout her hospitalization. Patient was unable to complete repeat video swallow studies given ongoing dizziness. Per note, later in hospital course, patient was found having difficulty with already modified dysphagia diet. Patient aspirated and developed likely aspiration pneumonia. Infectious disease contacted; patient finished a course of cefepime. Clinically, she continued to deteriorate with poor oral intake and ongoing weakness. Palliative care consulted. Family meeting occurred on 8/5/2022 with patient, husband, daughter, son on phone. After thorough discussion of progression of patient's chronic conditions without notable improvement over the course of hospital stay, family made shared decision to pursue home hospice. Patient was planning for transition to home hospice on 8/6/2022. On the evening of 8/5/2022, patient had another aspiration event leading to severe respiratory distress with hypoxemia. A rapid response was called as patient was having agonal/irregular breathing. Attempts were made to provide patient with supplemental oxygen and bedside cares. Patient was DNR/DNI. Family was contacted and ultimately decision made to make patient comfortable. Patient passed away on 8/5/2022 at 6:22 PM.