Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Blood culture positive, Blood lactic acid increased, Bradycardia, Brain injury, COVID-19
Clinical narrative: COVID+ -unsure-early November per report.  Vaccination status - Pfizer x4 Discharge Physician: MD Primary Care Physician: DO  Date of Admission: 11/26/2022 Discharge Date: 11/27/2022 Room Number:    BRIEF OVERVIEW:   Active Hospital Problems   Diagnosis Date Noted POA ? Acute hypoxemic respiratory failure  11/27/2022 No ? Hyponatremia 11/27/2022 Yes ? Lactic acidosis 11/27/2022 Yes ? Septic shock due to undetermined organism 11/26/2022 Yes ? Type 2 diabetes mellitus, without long-term current use of insulin  11/26/2022 Yes ? Cellulitis of right lower extremity 11/26/2022 Yes ? COVID-19 11/26/2022 Yes ? AKI (acute kidney injury)  11/26/2022 Yes ? Lung nodules 11/26/2022 Yes ? Hepatic steatosis 11/26/2022 Yes ? UTI (urinary tract infection) 11/26/2022 Yes ? Diarrhea 11/26/2022 Yes ? OSA (obstructive sleep apnea) 11/11/2020 Yes ? Multiple sclerosis, relapsing-remitting  08/24/2020 Yes ? Morbid obesity  02/17/2020 Yes ? HTN (hypertension) 08/31/2016 Yes ? Paroxysmal atrial fibrillation    DETAILS OF HOSPITAL STAY:  PRESENTING PROBLEM: Severe sepsis [A41.9, R65.20] Cellulitis of right leg [L03.115] Acute cystitis with hematuria [N30.01] Combined abdominal pain, vomiting, and diarrhea [R10.9, R19.7, R11.10] Severe sepsis with septic shock (CODE) [R65.21]  HOSPITAL COURSE:    Patient is a 66-year-old female with a history of MS on Ocrevus, afib on xarelto, diabetes, OSA and obesity who presented for evaluation of fever, right leg pain and diarrhea. All of these symptoms had onset of <24 hours.    In the ED the patient had severe lactic acidosis, leukocytosis along with fever, tachycardia and tachypnea. She was started on IV zosyn and IVF boluses. She had a CT abd/pelvis which was negative for acute process but did show right lung nodules and hepatic steatosis with recommendations for follow up nonemergent liver ultrasound and chest CT for further evaluation. Her UA was positive and urine culture was sent. The patient tested positive for COVID however she had COVID earlier this month and this was not felt to be a current infection. She had a negative CXR. She was admitted to the hospitalist team for further management of UTI, sepsis and cellulitis. Lactic acidosis and symptoms improved with IV fluids and Vancomycin + Ceftriaxone. Blood cultures positive for GPC, and lactic acid again began to increase. Antibiotics broadened to Vanc + Zosyn and patient transferred to ICU. She was awake and conversant and had acute onset of unresponsiveness with bradycardia on the monitor. Code was called and patient's rhythm was asystole. She received 40 minutes of CPR with multiple doses of epinephrine, vasopressin x1, and bicarbonate x1. ROSC was achieved. During the code, patient was intubated. General surgery was called in and performed arterial line and central line. Post arrest she was on levophed, vasopressin, stress dose steroids, Vancomycin, Cefepime, Metronidazole, and Clindamycin. Xarelto discontinued and pt transitioned to heparin gtt. Fluids transitioned to plasmalyte. Pt brought down for head CT which revealed no acute process with preservation of the gray-white matter differentiation. Patient transferred to ICU via ambulance with nursing care.  Electrolytes were monitored and repleted throughout the admission.  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Physician at Discharge: DO  Admission Date: 11/27/2022 DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Cardiac arrest [I46.9]   HOSPITAL COURSE: 66 y/o female with hx of MS (Ocrevus), morbid obesity, OSA (CPAP), A fib (Xarelto), HTN, DM-2 and COVID (+) early November. She was admitted to Hosp 11/26 with RLE cellulitis, Citrobacter UTI, lactic acidosis, AKI, Strep pyogenes bacteremia and septic shock requiring vasopressors. Was also found to be again COVID-19 positive. Course was complicated by asystolic and PEA cardiac arrest early 11/27 which was preceded by labored breathing and hypoxemia. ROSC was achieved after ~ 40 minutes of CPR and patient was intubated after multiple attempts with vomiting during tube placement. CXR following intubation showed the development of diffuse bilateral airspace disease. Labs were significant for progressive AKI and worsened lactic acidosis. Head CT showed no acute abnormality. Transferred to ICU 11/27 with significant FIO2 and vasopressor requirements. CRRT started. Echo showed mild concentric LVH with no WMAs, normal systolic and diastolic function. cEEG without seizure but showed marked burst-suppression indicating severe encephalopathy. Course complicated by persistent lactic acidosis, transaminitis and thrombocytopenia. Repeat CTH suggestive of global anoxic brain injury. CT of RLE showed edema along superficial muscle fascia - evaluated by ortho - unlikely to be necrotizing fasciitis given clinical improvement (also very high surgical risk). CT of chest, abdomen, pelvis showed L>R airspace disease, fatty liver, mild anasarca, no bowel ischemia. MRI brain 11/30 with global hypoxic ischemic injury. Transitioned to comfort care.  Time of death 1608 12/2/22.  Family at bedside