Age: 79.0
Sex: F
Vaccine: COVID19, FLUA4
Symptoms: Pleural effusion, Pneumonia aspiration, Pulse absent, Pupil fixed, Red blood cell transfusion
Clinical narrative: Discharge Provider: MD Primary Care Physician at Discharge: DO Admission Date: 2/18/2023  PRESENTING PROBLEM: Pancytopenia   HOSPITAL COURSE:   80 year old femal with past medical history significant for RA, CHB s/p dcPPM, CAD, AS s/p TAVR, HFpEF who presented with hypoxia and new O2 req. Recent admission for same found to have rib fractures and hemothorax. Presenting with b/l effusions L>R loculated, worsened from last admission. Also evidence of bronchial debris on left concerning for aspiration. Transferred here for further management and workup of pancytopenia, which has been present intermittently since 9/2021 (at that time, underwent BM Bx and comprehensive workup which was negative for heme malignancy / MDS, thought to be multifactorial ie CKD, chronic blood loss, chronic inflammation 2/2 RA).   This admission was found to have Streptococcus sanguinis bacteremia felt to be likely from aspiration pneumonia with loculated pleural effusions.  She was covered with IV antibiotics with IV Unasyn to complete a 7 day course as recommended by Infectious Disease.   Pulm eval for bilateral persistent effusions.  Recommended bilateral thoracentess.  IR consult for drain placement and she had left-sided pleural drain placed on 02/21 with right-sided thoracentesis.  Fluid studies consistent with exudative pleural effusion.  During admission she was also found to be COVID-19 positive; however, unclear if contributing to any her for current active medical issues.   In terms of her pancytopenia, Hematology was consulted who recommended bone marrow biopsy to workup which patient refused multiple times.  Etiology of pancytopenia was felt possibly secondary to methotrexate use with possible component of sepsis contributing.  Patient's blood pathology came back suggestive as well of immunosuppressive medication as well as sepsis for possible etiologies for pancytopenia.  Patient needed multiple transfusions of packed RBCs and platelets during admission.   Despite appropriate medical therapy patient declined.  Patient expressed that she did not wish to continue with any further invasive procedures if possible.  She did develop metabolic encephalopathy and DPOA was activated with her sons who were co-DPOAs.   Palliative care was consulted.  Goals of care was held with patient's family members and patient was transitioned to comfort care on 02/23.  Felt to be GIP appropriate and admitted to GIP hospice 2/23. Patient peacefully passed away 02/24/2023 08:32 PM   Please see attendings attestation for further information.    I was paged to patient?s bedside at 19:57 PM by remote physician due to concern that the patient had passed.  No spontaneous movements were present. There was no response to verbal or tactile stimuli. Pupils were dilated and fixed. No breath sounds were appreciated over either lung field. No carotid pulses were palpable. No heart sounds were auscultated over the entire precordium.  Patient pronounced deceased at 20:32 on 02/24/2023 Family at bedside were notified. They will make funeral arrangements at Funeral Home. Family was notified to contact funeral home. Attending to be notified in the morning.