Age: 71.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Haemorrhage, Haemothorax, Intensive care, Lethargy, Lung cancer metastatic
Clinical narrative: 1/9/22-72-year-old female with history of hypertension, hyperlipidemia, hypothyroidism, COPD, stage IV NSCLC with brain mets s/p RT/chemo presenting with complaints of SOA.  She states that symptoms have been present for about 5 to 7 days.  She recently tested positive for COVID 19 viral infection 1/7/2022.  Her primary care doctor has been managing her as outpatient.  She was supposed to go for monoclonal antibody infusion, however she states that she did not go as she did not want to bother her sister for a ride.  She was recently started on Augmentin for suspected superimposed bacterial pneumonia.  She states that she is currently receiving chemotherapy in oncology clinic.  She has had a fair appetite. She has had a fair appetite.  She denies any nausea, vomiting, diarrhea.  She admits to body aches, cough, SOA, sputum production. Review of Systems:  Constitutional: Denies fever or chills.  Reports lethargy Eyes: Denies change in visual acuity  HENT: Denies nasal congestion or sore throat  Respiratory: Reports cough and shortness of breath  Cardiovascular: Denies chest pain, palpitations, or edema  GI: Denies vomiting, bloody stools or diarrhea. Denies abdominal pain, nausea  GU: Denies dysuria  Musculoskeletal: Denies back pain or joint pain.  Reports myalgias Integument: Denies rash  Neurologic: Denies headache, focal weakness or sensory changes  Endocrine: Denies polyuria or polydipsia  Lymphatic: Denies swollen glands  Psychiatric: Denies depression or anxiety   ICU NOTE  CXR this am reveals 4cm pneumothorax on the right side.  Patient on full dose lovenox.  Proceeded with emergency seldinger 18f chest tube placement.  Patient then began bleeding from her airway and I converted to traditional surgical chest tube placement.  CXR obtained and thoracostomy tube in good position on the right with inflated lung.  Infiltrate worse.    Airway bleeding subsided but then patient was peak pressuring on the ventilator and not receiving tidal volumes.  Blood pressure dropping.  Suspected airway obstruction.  Using the disposable bronchoscope I discovered quite a bit of blood clot in the distal endotracheal tube stranding and connected to large clot burden in the right main stem.  I was unable to remove clot.     Changed to BMV and blood pressure improved.  Had to add levophed.  Endoscopy team called and they have just arrived to bedside.      Discussed case with daughter.  All the patient's issues stem from cancer.  She would not want chest compressions on her mother.  DNR ordered.    FINAL DIAGNOSES 1. COVID-19 pneumonia with severe sepsis and acute respiratory failure POA 2. Bacterial pneumonia 3. Acute DVT 4. Acute kidney injury 5. Hemothorax 6. Transaminitis 7. Pulmonary hemorrhage 8. Thrombocytopenia 9. Metastatic lung cancer HOSPITAL COURSE 72-year-old female with metastatic lung cancer to the brain presents with shortness of breath.  She was recently diagnosed with COVID.  She may have overlying bacterial pneumonia.  The patient was treated with dexamethasone, baricitinib, and antibiotics.  She is also found to have acute DVT and was started on Lovenox.  She has developed an acute kidney injury and severe transaminitis.  She also has underlying thrombocytopenia.  The patient deteriorated requiring transfer to the ICU.  She had a hemothorax therefore chest tube was placed, then this was followed by severe hemoptysis.  Bronchoscopy showed large amount of blood.  As the patient was transferred back to the ICU the family had decided on comfort care.  She expired shortly thereafter peacefully.