Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: Hypotension, Immature granulocyte count, Infection, Inflammatory marker test, Intensive care
Clinical narrative: 1/2/22 86 yr/o male who presents with low blood pressure which began yesterday. History is obtained through the son who is translating for the patient. The son states that the patient has baseline confusion and is unable to contribute to the history. The son reports that yesterday his blood pressure was in the 50s systolic and this morning it was in the 70s systolic. Son relates that the patient vomited yesterday. He has been generally weak and unable to walk since yesterday. He had a fall 2 days ago but the son reports that it was not a bad fall. Son reports that he is complaining of low back pain. But he has not complained of any chest or abdominal pain headache or other complaints. But has not he has not complained of any chest or abdominal pain headache or other complaints. He has had a cough. There is no report of fever. Patient has had 2 Covid vaccinations. Review of Systems: Respiratory: Positive for cough. Gastrointestinal: Positive for vomiting. Musculoskeletal: Positive for back pain. Neurological: Positive for weakness. Psychiatric/Behavioral: Positive for confusion. ROS is limited in this patient who has baseline confusion and does not speak English, CBC W/DIFF - Abnormal, White Blood Count 9.45  4.5 - 11.0 10*3/uL, Red Blood Count 4.10 (*) 4.5 - 5.9 10*6/uL, Hemoglobin 12.6 (*) 13.5 - 17.5 g/dL, Hematocrit 39.3 (*) 41.0 - 53.0 %, Mean Corpuscular Volume 95.9  80.0 - 100.0 fL, Mean Corpuscular Hemoglobin 30.7  26.0 - 34.0 pg, Mean Corpuscular HGB Conc 32.1  31.0 - 37.0 g/dL, Red Cell Distribution Width-CV 12.5  12.0 - 16.8 %, Platelet Count 170  140 - 440 10*3/uL, Mean Platelet Volume 10.0  8.4 - 12.4 fL, Diff Type Hospital CBC w/AutoDiff  (arb'U), Neutrophils % 82.0 (*) 45 - 80 %, Lymphocyte % 9.5 (*) 15 - 50 %, Monocyte % 6.1  0 - 15 %, Eosinophil% 1.8  0 - 7 %, BASO% 0.2  0 - 2 %Immature Granulocyte% 0.4  0.0 - 1.0 %, Nucleated RBC % 0  0 /10, 0(WBC), Neutrophil Abs 7.74  2.0 - 8.8 10*3/uL, Lymphocyte-Absolute 0.90  0.7 - 5.5 10*3/uL, Monocyte Absolute 0.58  0.0 - 1.7 10*3/uL, EOS-Absolute 0.17  0.0 - 0.8 10*3/uL, Basophil Abs 0.02  0.0 - 0.2 10*3/uL, Immature Granulocyte Abs 0.04  0.00 - 0.10 10*3/uL. COMPREHENSIVE METABOLIC PANEL (CMP) - Abnormal, Sodium 137  136 - 145 mmol/L, Potassium 4.8  3.5 - 5.1 mmol/L, Chloride 110 (*) 98 - 107 mmol/L, Carbon Dioxide 14 (*) 22 - 29 mmol/L, Anion Gap 13  5 - 13 (arb'U), Glucose 141 (*) 74 - 99 mg/dL, Blood Urea Nitrogen (BUN) 49 (*) 8 - 26 mg/dL, Creatinine-Blood 2.69 (*) 0.73 - 1.18 mg/dL, BUN/Creatinine Ratio 18.2  RATIO, Estimated GFR 23 (*) >60 /1.73 m2, Estimated GFR if African-American 27 (*) >60 /1.73 m2, Total Protein 7.4  6.2 - 8.0 g/dL, Albumin 3.6  3.2 - 4.6 g/dL, Globulin 3.8  1.5 - 4.5 g/dL, Albumin/Globulin Ratio 0.9 (*) 1.1 - 2.5 RATIO, Calcium 8.2 (*) 8.4 - 10.2 mg/dL, Total Bilirubin 0.7  0.2 - 1.2 mg/dL, AST/SGOT 35 (*) 5 - 34 U/L, ALT/SGPT 20  0 - 55 U/L, Alkaline Phosphatase 58  40 - 150 U/L. LACTIC ACID - Abnormal, Lactic Acid  2.1 (*) 0.7 - 2.0 mmol/L. CULTURE, URINE, CULTURE, BLOOD. TROPONIN, Troponin <0.010  0.000 - 0.034 ng/mL. B-TYPE NATRIURETIC PEPTIDE, B-Type Natriuretic Peptide 28.0  4 - 254 pg/mL. LIPASE, Lipase 33  4 - 39 U/L. URINALYSIS, Color-Urine Yellow, Clarity-Urine Clear. Specific Gravity Urine 1.010  1.005 - 1.030 (arb'U), pH-Urine 5.0  5.0 - 9.0 (pH), Protein-Urine Negative  Negative mg/dL, Glucose-Urine Negative  Negative mg/dL, Ketone-Urine Negative  Negative mg/dL, Bilirubin-Urine Negative  Negative mg/dL. Occult Blood-Urine Negative  Negative (arb'U), Nitrite-Urine Negative  Negative (arb'U), Urobilinogen-Urine Normal  Normal (EhrlichU)/dL, Leukocyte Esterase-Urine Negative  Negative (arb'U), Source-Urine Urine Midstream. Reflex Microscopic? Macroscopic only performed. 1/2/22 XR Chest 1 Vw  IMPRESSION: 1. Extensive airspace disease in the right lung may represent pneumonia. Would recommend radiographic follow-up to resolution. 2. Patchy airspace disease in the left lung base may represent atelectasis and/or pneumonia. Discharge Diagnoses: Principal Problem: Pneumonia due to COVID-19 virus (1/2/2022). Active Problems: AKI (acute kidney injury) (1/2/2022), Severe sepsis (1/2/2022), Metabolic acidosis (1/2/2022), BPH (benign prostatic hyperplasia) (6/1/2015), Vascular dementia (6/10/2015), Type 2 diabetes mellitus without complication, without long-term current use of insulin (8/18/2020). H/O: CVA (cerebrovascular accident) (1/2/2022), Acute respiratory failure with hypoxia (1/3/2022). History of Present Illness: Patient is not a good historian. History taken from son who speaks some English and the ED staff. This is an 86 yr/o male who presents with low blood pressure which began yesterday PTA. History is obtained through the son who is translating for the patient. The son states that the patient has baseline confusion and is unable to contribute to the history. The son reports that yesterday his blood pressure was in the 50s systolic and this morning it was in the 70s systolic. Son relates that the patient vomited yesterday.  He has been generally weak and unable to walk since yesterday. He had a fall 2 days ago but the son reports that it was not a bad fall.  Son reports that he is complaining of low back pain. But has not he has not complained of any chest or abdominal pain headache or other complaints. He has had a cough. There is no report of fever. Patient has had 2 Covid vaccinations. 1/11/22  Hospital Course: Pneumonia due to COVID-19 virus/Acute Hypoxic Respiratory Failure, Inflammatory markers improving, Started IV Decadron and Remdesivir - continue same, Baricitinib added 1/4 after transfer to ICU, CAP/aspiration antibiotics to continue - day 8 of 10, Pulm on consult - appreciate assistance, Back on BiPap - D-dimer notable jump 10k to 21k. AKI with metabolic acidosis and hypernatremia. Hx of BPH and urinary retention, Likely pre-renal ATN. Renal US with no hydro, Monitor UOP and serial labs, Continue Flomax, Renal consulted - appreciate assistance, Creatinine overall mildly improved but not at baseline. Continuing FW for hypernatremia and adding D5W IVF. Severe sepsis, POA, From COVID and likely underlying aspiration pneumonia. IVF, supportive care, and treat underlying infections, Back on Pressors as of 1/10 - likely r/t sedation. Vascular dementia/H/o CVA. Delirium vs metabolic encephalopathy, PT/OT when appropriate. Continue aspirin, Minimizing sedating meds as able. Correct metabolic derangements. Type 2 diabetes mellitus without complication, without long-term current use of insulin, Mildly uncontrolled. Was on adjusted Lantus and ISS. Patient was made DNR/DNI during his admission by family, and today his respiratory status worsened to the point he could no longer sustain himself. He passed naturally at 13:50 on 1/11/2022. Cause of death is acute respiratory failure from COVID pneumonia and a possible secondary bacterial pneumonia. I have spoken to the patient's son today, he understands his hospitalization course.