Deceased (4.30.22); Hospitalized (4.14.22); COVID-19 positive (4.11.22-home test); Fully vaccinated plus booster - pfizer x3 4/15/22 pulm H&P:  HPI: History obtained from the chart since patient was intubated in the ED. He presented with worsening shortness of breath in the setting of testing positive for COVID about 4 days prior. He was initially 89% on RA but HR was in the 160s, afib. He progressed to having more tachypnea and more respiratory distress so was eventually intubated.    Upon arrival to the MICU patient's heart rate persisted in the 160s with evidence of LBBB. Blood pressure progressively dropped.  ROS: unable to obtain due to mechanical ventilation and sedation FIO2 (%): 90 % Type of Mechanical Vent: Hamilton Mechanical Rate: 32 breaths/min Set/Target Tidal Volume: 500 PEEP (cm H2O): 14 cm H2O EPAP: 5 IPAP: 16 cmH2O Inspiratory Time Set: 0 second(s) Intubated, sedated No scleral icterus Moving air well anteriorly Abd soft No pitting LE edema Synchronous on the vent A/P: Acute hypoxic resp failure COVID pneumonia - Decadron 6mg daily - Supportive care with mechanical ventilation - Low tidal volume ventilation with goal Tv 4-6mL/kg. Target Dp <14 and Pplat <30 - Check D-dimer and CRP - Tocilizumab still on shortage - Needs bronch with BAL to guide de-escalation of antibiotics - Okay to continue empiric coverage for now Shock - Unclear etiology - Has known ischemic cardiomyopathy, last EF 55% from 2018 - Repeat echo - Stress dose steroids (hydrocortisone added in addition to Decadron for more mineralocorticoid effect) - Trial of IVF bolus, though no more than 1L due to resp failure - Check central venous O2 sat Afib with RVR Left bundle branch block History of ischemic cardiomyopathy - Discussed with Cardiology given concern for new LBBB. Appears to be rate dependent with improvement once rate controlled - Started on amio drip, will continue - aspiri - hold statin due to rising AST and ALT AKI - Likely due to shock/hypotension - Trend, avoid nephrotoxins, renally dose meds Elevated AST and ALT - Possibly due to hypotension - Trend - No statin History of HIT - no heparin products - Fondaparinux for DVT prophylaxis FEN/GI - fluid boluses as needed - potassium hemolyzed, repeat labs - NPO but assess with daytime team - Fondaparinux for DVT  proph - PPI for GI proph FULL CODE This patient is critically ill and is requiring active support and intensive surveillance to prevent life threatening clinical deterioration.  I spent a total of 80  minutes in the evaluation and management of this patient excluding all procedures  4/29/22 General Med Progress note:CHIEF COMPLAINT: Pneumonia due to COVID-19 virus ASSESSMENT / PLAN:   65-year-old man with a complex past medical history, including atrial fibrillation status post Watchman, heart failure with preserved ejection fraction, coronary artery disease, hypertension, type 2 diabetes, cirrhosis, history of HIT, as well as hyperlipidemia and alcohol use disorder. He presented with respiratory failure secondary to COVID-19 pneumonia; intubated from 04/15 through 4/19.  Patient also had shock requiring pressors and stress dose steroids.  Completed methylprednisolone through 04/24/2022.  Remdesivir not completed secondary to elevated LFTs.   Hospital course now complicated by toxic metabolic encephalopathy and delirium.  Psychiatry following along.  Likely multifactorial related to post intensive care unit stay, COVID-19, altered sleep-wake cycle, hepatic encephalopathy in setting of cirrhosis.  Receiving Zyprexa.  Patient also with acute kidney injury requiring hemodialysis and worsening respiratory distress/leukocytosis now being treated for possible secondary bacterial pneumonia.      # Acute Hypoxemic Respiratory Failure Secondary to COVID-19 Pneumonia: # Leukocytosis and Possible secondary Bacterial Pneumonia (4/25) Patient vaccinated for COVID.  Tested positive 4/11/2022. Intubated 4/15 through 4/19, but had been able to wean to room air. CT angiogram thorax 04/15/2022 extensive airspace disease bilaterally, no central, lobar proximal pulmonary embolism.  Chest x-ray 04/19/2022, shallow inspiration concerning for congestive heart failure.  Independently reviewed chest x-ray from 04/24/2022, clearing of the right lung base, limited his ability to the retrocardiac space, no definite infiltrates.   Bronchoscopy completed 04/15/2022, cultures negative.  Film array positive for COVID-19.   Patient received dexamethasone 6 mg 04/15/2022, then received stress dose steroids changed to methylprednisone 60 mg daily from 04/17 to 4/24 to complete a 10 day course. Received remdesivir for single dose, but then held given elevated LFTs. Covid infection also complicated by AKI as discussed below Patient with worsening respiratory distress, rising WBC and elevated Procal (1.0) on 4/25. (Although prior procal 4.79 on 4/15). Started on IV cefepime and vancomycin (Renally dosed) due to concern for secondary bacterial PNA. -Procal down trending to 0.55 on 4/27 and although increased resp distress and requiring 4-5L O2 via NC on 4/27, CXR with improvement. Resp status stable on 4/28, but no improvement/change overall from day prior.  -Started on vanc and cefepime for a 5 day course (EOT 4/29). - Continue incentive spirometry, prone positioning if able - Wean supplemental oxygen as able - DVT prophylaxis with Eliquis 2.5 mg twice daily given HIT history. Mobilize as able.    # AKI:  Currently hemodialysis dependent MWF.    # Worsening Uremia with Dialysis catheter malfunction Nephrology consulted and following, appreciate their recs AKI suspected to be a ischemic acute tubular necrosis in the setting of shock. COVID-19 can also cause renal injury such as FSGS and thrombotic microangiopathy. Patient currently requiring intermittent hemodialysis for renal function and volume control.  However, neph reporting they are having problems with his dialysis catheter. They attempted TPA his last 2 sessions without resolution. Was not able to attempt HD today.  BUN elevated 138->162 on 4/29 PM. Pt becoming more altered. IR consulted to replace line with plan for HD session on 4/30 AM. Will continue to monitor renal function, electrolytes, and mental status closely. May need more urgent HD if any clinical worsening. (Was called to the bedside by RN this afternoon since pt much more somnolent. Reportedly only minimally responsive to pain/sternal rub. When I arrived, patient able to alert more to loud noises/slamming of the door. He was spontaneously making eye contact, but remained non-verbal and quickly falling back asleep.)  Avoid nephrotoxic agents.   Continue PhosLo with meals # AMS, Agitation - Suspect multifactorial related to Toxic Metabolic Encephalopathy (COVID 19/AKI)/Hepatic Encephalopathy, Post ICU Delerium, Steroid Use:   Workup thus far includes CT head with no acute intracranial process, ammonia level elevated at 70, but lower since. TSH 1.2.  Vitamin B12 normal. Vitamin B1 pending. VBG with no CO2 retention on multiple checks. EEG revealed mild-to-moderate background slowing, bitemporal slow waves, GRDA slow posterior dominant rhythm consistent with mild-to-moderate cerebral dysfunction and encephalopathy.  No seizures were identified. Exam remains Nonfocal. No nuchal rigidity or headache reported.  -Psychiatry consulted. Appreciate their recs - Pt with continued waxing/waning mental status - Continue with Zyprexa 5 mg daily and p.r.n. (Psych initially recommended increasing dose to BID, but given not taking PO meds consistently on 4/27 so continue current dose for now. Added PRN IM Zyprexa as alternative) - Continue Bilateral soft wrist restraints as needed (currently in place). - Continue IV thiamine 100mg daily given alcohol use history. Will continue lactulose 3 times a day and rifaximin 2 times a day (encouraged nursing staff to keep offering PO meds once mental status showing signs of improvement).  Titrate lactulose to 3 loose stools per day. (If pt too agitated, would give lactulose rectal as needed) - AMS worsening 4/28-4/29 in setting of rising BUN and ineffective HD sessions as noted above #Decreased Responsiveness Episode Following HD (x2 episodes):   Patient had some hypotension during hemodialysis 4/25 and again 4/27.  Following that, patient had an episode of decreased responsiveness.  By the time the team arrived at the bedside, patient was awake, interactive (happened both times).   This does not appear consistent with acute CVA; however, stat head CT was ordered with initial episode and negative. Neurology was contacted.  -Still plan to attempt MRI brain once patient less agitated and respiratory status improved. (Wife states pt with anxiety/claustrophobia at baseline to unlikely to tolerate MRI without some sedation.)   - Repeated infectious work-up 4/25 with complete blood count (rising WBC), BMP, ammonia level (stable), lactic acid (neg), chest x-ray ordered to evaluate for alternative etiology of transient decreased responsiveness. CXR with worsening atelectasis vs infiltrate. Started on IV cefepime and vancomycin and treatment for secondary bacterial PNA and HAP as discussed above # New LBBB:   Noted troponin elevation 39, repeating to 52. Appreciate cardiology input, prior to discharge ischemic cardiac workup is planned. # Transaminitis:   Patient with significant elevation in AST 3571 and ALT 2029. LFTs have been trending down.  Right upper quadrant ultrasound with Doppler reveals surface nodularity and hepatocellular disease.  Small amount of ascites, portal venous hypertension. Gallbladder wall thickening and hepatic waveform in the liver can be seen with heart failure.  Clinical trajectory seems most consistent with shock liver.  Liver toxicity related to amiodarone also should be considered, though given the trajectory of the LFT elevation well amiodarone is being continued make this less likely. # Chronic HFpEF now with Acute Cardiomyopathy - Echo 4.22.22 EF 25% with global LV dysfunction with moderate to severe RV dysfunction.  Pt was on BID IV Lasix 80 mg for volume control in addition to hemodialysis. Lasix held 4/27. 2 g sodium and 2 L fluid restriction. Appreciate cardiology input. # RV Dysfunction:   Echocardiogram 4/22/22 revealed moderate to severe RV dysfunction. May need to consider PAH workup as well, with comprehensive ECHO. CTA showed no Pulmonary Embolism.  Discussed with Cardiology and at this point, we are holding off on further cardiac evaluation until patient is approaching discharge. # Shock: resolved.   Etiology was not clear, pan cultures negative.  Patient received stress dose steroids, and vasopressin and norepinephrine have been discontinued since 04/19/2021. Shock has resolved.   # Liver Cirrhosis:  MELD 26. Currently decompensated.  Right upper quadrant ultrasound completed as outlined above, revealing cirrhosis.  Continue lactulose for hepatic encephalopathy with rifaximine.  Small amount of ascites, likely too small to pursue safe paracentesis, no abdominal pain.  Monitor INR, LFTs daily.  Spironolactone on hold # Afib with RVR:   Chads Vasc is 3. Patient status post Watchman.  Given amiodarone load and now on amiodarone 200 mg daily.   Rate control currently acceptable.   Continue metoprolol at 50 mg 3 times a day.  (If patient remains altered and unable to tolerate PO meds, will transition back to IV)  Will defer resuming digoxin to the cardiology team. # Elevated D-Dimer:   Significant elevation to 12,000 on admission.  CT angiogram revealed no evidence of pulmonary embolism.  Upper and lower extremity ultrasounds were obtained which did not reveal DVT.  Patient was empirically on a agatroban, this has been discontinued by the critical care team.  Initiated on Eliquis 2.5 mg twice daily for DVT prophylaxis given the patient is unable to receive fondaparinux given renal function.   # Previous HIT: Avoid all heparin products. # Visual Hallucinations:  Seem resolved # DM2:  Goal blood sugar 140-180. Patient remains above goal with variable oral intake in the setting of AMS. Glu up to 500s on 4/28 PM, now improving to 200s. Management per the endocrinology team. # HTN:  Continue metoprolol 50 mg every 8 hours.  If pt consistently altered/refusing PO meds, will transition to IV metoprolol.  # HLD/CAD:  Aspirin, holding statin given elevated LFTs.  Non-invasive ischemic workup closer to DC # Urinary Retention: improved Straight cath PRN #Limited oral intake #Deconditioning:  Oral intake remains poor. Started on calorie count 4/28 Wife considering enteral nutrition/ corpak placement if needed. However, will continue to monitor oral intake.  Continue PT and OT,  consider acute rehab as he approaches discharge. # Hyperphosphatemia: Continue Phoslo.  Continue daily creatinine, complete blood count with differential, and liver function lab monitoring while on IV antibiotic (vancomycin and cefepime) to monitor for renal, myelotoxicity, and hepatoxicity. SUBJECTIVE/Interval History: Patient remains much more somnolent and altered than days prior.  Discussed with Nephrology this morning.  Patient has been having problems with his dialysis catheter this entire week.  They attempted to tPA the line the last 2 dialysis sessions; however, they continued to have problems.  Patient's labs remain concerning, with rising BUN level.  Concerned that this is likely contributing to his altered mental status.  Patient was not able to complete any of his HD session this morning.  IR was consulted for line replacement, but due to emergent cases, this may not be completed until tomorrow morning.  Son at the bedside was very concerned regarding patient's mental status.  I discussed patient's abnormal lab results and how this was not too unexpected.  We reviewed patient's previous chest x-rays, CT chest, and earlier hospital imaging at the bedside.  Noted overall improvement in patient's imaging.  Answered son's additional questions and reassured him of plans of care.  OBJECTIVE: BP 149/91  | Pulse 84  | Temp 36.9 °C (Axillary)  | Resp 26  | Ht 1.88 m  | Wt 107 kg  | SpO2 100%  | BMI 30.29 kg/m²  FIO2 (%): 25 % Physical Exam Constitutional:      General: He is in acute distress.     Appearance: He is ill-appearing. He is not toxic-appearing.     Comments: Somnolent  HENT:     Head: Normocephalic.     Nose: No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are dry.     Comments: Resting primarily with mild gaping open, mucous membranes dry Eyes:     General: No scleral icterus.    Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Neck:     Comments: R IJ catheter place Cardiovascular:     Rate and Rhythm: Regular rhythm. Tachycardia present.     Pulses: Normal pulses.     Heart sounds: No murmur heard. Pulmonary:     Effort: Respiratory distress present.     Breath sounds: Rales present. No wheezing.     Comments: Diminished at b/l bases with a few faint crackles (L>R), mild tachypnea with increased subcostal retractions compared to day prior, intermittent stertorous breath sounds, protecting airway in maintaining saturations on 5 L O2 via nasal cannula Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No tenderness.     Cervical back: Neck supple.     Comments: 1 to 2+ proximal hip edema, trace bilateral leg edema  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     Mental Status: He is disoriented.     Comments: Somnolent but did spontaneously open eyes and track intermittently, nonverbal today, quickly falls back asleep