Date of Service Mar-02-2022 1246  Date of Admission Admit Date: Feb-25-2022  Date of Discharge Date of discharge Mar-02-2022  Allergies Atorvastatin - Not Specified  Cyclobenzaprine - Not Specified  Sulfa Antibiotics - Not Specified  Final Diagnoses COVID-19 Onset Feb-25-2022  Acute respiratory failure  Mantle cell lymphoma  Pneumonia  Procedure(s) Performed None  Lab Results Mar-02-2022 0656 Chemistry GLUCOSE  188BUN  18CREAT  1.0MDRD GFR  54NA  142K  3.2CL  100CALCIUM  8.6CO2  35.0OSMO  290.0ANION GP  10.2BUN/CRE  18.0MAGNESIU  1.8PHOSPHOR  2.9 Mar-02-2022 0656 Hematology WBC  5.1RBC  3.33HGB  10.4HCT  30.7MCV  92.2MCH  31.2MCHC  33.9RDW  12.8RDWSD  43.2PLT  116MPV  11.3AUTONEU%  83.4AUTOLYM%  9.7AUTOMON%  4.7AUTOEOS%  0.0AUTOBAS%  0.2AUTONEU#  4.2AUTOLYM#  0.5AUTOMON#  0.2AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.4NRBC  0.0HGB/HCT  3.0IG#  0.10IG%  2.0 Mar-02-2022 0540 Point Of Care GLUSTX  202 Mar-01-2022 2038 Point Of Care GLUSTX  271 Mar-01-2022 1709 Point Of Care GLUSTX  245 Functional Status* Expired  Mental Status* Expired  Social History tobacco use Never Smoked, Smoking Cessation Not Applicable NA  marital status Widowed  Health Concerns COVID-19  Acute respiratory failure  Cyst of pancreas  Iron deficiency anemia  Hypothyroidism  Hyperlipidemia  Mantle cell lymphoma  Carotid artery stenosis  Obstructive sleep apnea of adult  Essential hypertension  Chronic kidney disease stage 2  Atrial fibrillation  Chronic diarrhea  Type 2 diabetes mellitus  Chronic obstructive lung disease  Pneumonia  Father Deceased Old-age @ 85  Mother Deceased Multiple malignancy @ 82  Vital Signs Mar-02-2022 0500 HR 81 RR 20 BP   148 / 69 O2Sat 91 Mar-02-2022 0400 HR 66 RR     34 BP   147 / 58 O2Sat     87 Mar-02-2022 0200 T 98.5 Mar-01-2022 2200 T 97.9 PHYSICAL EXAM Patient expired, see death note.  Hospital Course Patient is a 76-year-old female patient of Dr. who was admitted on 2/25/22 for multifocal pneumonia, persistent COVID-19 infection, and possible heart failure exacerbation. She has a past medical history significant for mantle cell lymphoma, atrial fibrillation on Xarelto, hypertension, obstructive sleep apnea, type 2 diabetes on metformin, hypothyroidism, depression, hyperlipidemia, grade 3 diastolic heart failure, and carotid artery stenosis.   Throughout her hospital course the patient continued to worsen clinically and was diagnosed with ARDS on 02/20/2022 after acutely worsening the night before.  The patient's oxygen requirements continued to increase despite attempts to diurese as well as attempts to treat secondary bacterial infections.  Supplementation was started via TPN attempt to help improve the patient's weakness but did not have any noticeable benefit clinically.  On the night of 03/01/2022, the patient experienced significant oxygen desaturations into the 70s and 80s despite being on maximum CPAP  Settings.  And earlier trial at a on BiPAP to see if the patient might have an easier time breathing failed.  Despite having the patient tolerated the BiPAP, she experience worsening hypoxia BiPAP settings.  On the morning of 03/02/2022, the patient had  recovered somewhat and maintain  oxygen saturations above 80% however she  was becoming increasingly tachypneic and fatigued.  She stated to me during my examination with her as she "feels was ready to give up and was tired of fighting this".  She repeated a similar statement to the nursing team as well as to Dr. and myself. off of a later point in the morning while rounding. I met with the patient's family to update them on her condition at which point I went to the room with the family to visit the patient again expressed that she was tired of fighting and was okay with comfort measures.  I assess that she was alert and oriented x4 and was able to make her own medical decisions.  She voiced understanding that transitioning to comfort care would mean that she would likely die soon and that we would focus our efforts are making her comfortable on her final moments.  Patient was placed on standard comfort care measures including morphine for pain her hunger, Ativan for anxiety agitation, and chronic apparently for secretions.  Her morphine dose had to be increased both in frequency and and concentration several times to meet demands for her air hunger after CPAP was removed.  At 12:36 p.m. telemetry noted that she had entered asystole after which Dr myself performed on examination a pronounced her deceased.  Please see death note.  Condition at Discharge Expired  Discharge Disposition Expired  Plan Assessment:  - Acute hypoxic respiratory failure secondary to multifocal pneumonia, requiring 2L NC on admission 2/25/22,  worsening - Acute respiratory distress syndrome, likely secondary to COVID-19 pneumonia. - Multifocal pneumonia, COVID-19 pneumonia with possible superimposed bacterial pneumonia on admission 2/25/22 - Mild exacerbation of heart failure with preserved ejection fraction, grade III diastolic dysfunction per echocardiogram 2/26/22, proBNP 1,329 on admission 2/25/22 - Hypomagnesemia, acute, magnesium 1.3 on admission 2/25/22. - Elevated D-dimer, acute, d-dimer 1.97 on admission 2/25/22, CTA negative for embolism, likely secondary to COVID-19 infection - Acute kidney injury on chronic kidney disease 3A, baseline GFR 54, creatinine 1.3 on admission 2/25/22, resolved - Debility, acute, secondary to long-COVID, acute bacterial pneumonia, and dehydration - Vitamin B12 deficiency, unknown chronicity, vitamin B12 133 on 2/26/22, likely secondary to chronic conditions, on daily 1,000u subq injections 2/26/22 - Pancytopenia, chronic, likely secondary to chemotherapy for mantle cell lymphoma - Functional diarrhea, acute on chronic, likely secondary to COVID-19 - Iron deficiency anemia, chronic, unknown control, iron 21 on 2/25/22 - Atrial fibrillation, chronic, rate controlled - Obstructive sleep apnea, chronic, on CPAP at night - Chronic obstructive lung disease, unknown GOLD stage - Essential hypertension, chronic, unknown control - Hypothyroidism, chronic, unknown control - Type 2 diabetes mellitus with peripheral neuropathy, chronic on metformin, last HgA1c 6.3 on 10/19/21 - Generalized anxiety disorder, chronic, on Lexapro - Hyperlipidemia, chronic, on pravastatin - DNR/DNI code status  Plan:    Patient was placed on comfort measures on 3/2/22 after expressing a desire to do so.  At 12:36pm on 3/2/22, the patient was pronounced dead, see death exam note. Body released to Funeral Home per Family's wishes.    Electronically signed on Mar-02-2022 1307