Date of Admission  01/22/2022   Date of Discharge  01/27/2022   Reason for Hospitalization   Pt with ALS on trilogy presents with increased SOB, attempted to use machine to clear secretions but has not had luck..recent covid exposure  Hospital Course       Patient is a 69 y/o male with history of recently-diagnosed ALS on Trelegy NIPVV (on APRV ventilation), CVA x2 (residual par. L blindness, dysarthria), CAD s/p DES x2 (OM1, RCA, 2011) and BMS x1 (LAD 2015) on ASA, Afib on Apixaban, NIDDM2,and CKDG3A3 who presented to the ED on 1/22 with 1 day of worsening SOB and several days of fatigue and malaise, and was found to have Covid (antigen-, PCR+). Patient is triple vaccinated with booster. Sick contact appears to be daughter who was positive on Wednesday 1/19 but exposed patient on 1/18. In ED patient did not have increased O2 requirements but did have increased WOB. ED labs showed AG=14, mild lymphopenia, stable CKD, and Trop in 40's. Patient was admitted to the ICU for further care. He subsequently had multiple desaturations to the low 80s on home trilogy, so was switched to hospital BIPAP. Dexamethasone, Remdesivir, and Levaquin (CAP coverage) were administered. On 1/24, patient informed that he will likely need intubation due to worsening oxygenation but he would then likely become completely vent dependent with his current comorbidities and PMH. After discussion with patient and family in regards to considering intubation vs hospice/comfort care, home with hospice was chosen. Hospice referrals were made. Patient weaned from bipap back down to home Trilogy settings. Comfort care initiated 1/26 while on NIPPV. Patient discharged to home by EMS in stable condition with plan for home with hospice. Hospice E-kit ordered and sent to Pharmacy per wishes.  Discharge Diagnoses      Neuro:  #ALS  #Prior CVA  - ASA 81mg Qday (home med) held  - Riluzole 50mg BID (home med) cont  - Sertraline 150mg Qday (home med) held  - Gabapentin 600mg QHS PRN (home med) held  - Comfort care initiated  - Hospice E-kit ordered  Cardiology:  #History of CAD  #Atrial fibrillation on apixaban  - Holding anticoagulation for now in acute setting, see below.  Respiratory:  #Respiratory failure due to neuromuscular failure (ALS)  #Covid pneumonia  #Possible overlying community-acquired pneumonia  - Continue NIPPV while on comfort care  - dexamethasone last dose 1/26  - remdesivir d/ced  - comfort care initiated  Gastrointestinal:  #Dysphagia  #Cachexia   - Regular diet, comfort care  Renal/GU:  #CKD  - avoid nephrotoxic medications  Endocrine:  #T2DM  - SSI discontinued, comfort care  Heme:  No acute concerns  - No anticoagulation, comfort care  ID:  #COVID pneumonia  # possible overlying community-acquired pneumonia  - Dexamethasone last dose 1/26, remdesivir d/ced  - Covering for CAP w/ Levofloxacin 750mg Qday (PCN allergy =hives)  -BC x2 NGTD  -Sputum cx NGTD  - Urine strep/legionella negative  - RPP negative except SARS-COV2   Antibiotics:  Levofloxacin (1/22 - 1/26)  MSK:  #Muscle wasting  - PT/OT  Other Diagnoses   Ongoing  ALS (amyotrophic lateral sclerosis)  Back pain  Chronic anticoagulation  CKD (chronic kidney disease), stage III  Coronary artery disease  DM (diabetes mellitus), type 2, uncontrolled  Hyperlipidemia  Hypertension  Hypertensive heart disease  Occipital stroke  Permanent atrial fibrillation  Stroke due to embolism of right posterior cerebral artery  Historical  No qualifying data  Operations and Procedures   none  Consultants   Hospice eval and admission  Pending Labs  Culture Blood (Preliminary, InProcess, ordered 01/22/2022, 21:24)   Culture Blood (Preliminary, InProcess, ordered 01/22/2022, 21:24)   Discharge Disposition  Home, Hospice    Medications  New, Changed, or Refilled Medications  None    Medications to be Continued  amLODIPine (amLODIPine 5 mg) 5 mg, 1 Tablet(s), Oral, Daily, 90 Tablet(s), 3 Refill(s)    apixaban (apixaban 5 mg) 5 mg, 1 Tablet(s), Oral, qAM & Bedtime    aspirin (aspirin 81 mg oral EC 81 mg, 1 Tablet(s), Oral, Daily    calcitriol (calcitriol 0.5 mcg 1 mcg, 2 capsule(s), Oral, qM W F, 78 capsule(s), 3 Refill(s)    cholecalciferol (Vitamin D3 25 50 mcg, 2 capsule(s), Oral, Daily    furosemide (furosemide 40 mg) 80 mg, 2 Tablet(s), Oral, Daily    gabapentin (gabapentin 600 mg) 600 mg, 1 Tablet(s), Oral, At Bedtime    isosorbide mononitrate (isosor 30 mg, 1 Tablet(s), Oral, qEvening    losartan (losartan 50 mg) 50 mg, 1 Tablet(s), Oral, bid    polyethylene glycol 3350 (Mira 17 g, Oral, Daily, PRN: Constipation    riluzole (riluzole 50 mg) 50 mg, 1 Tablet(s), Oral, bid    rosuvastatin (rosuvastatin 40 40 mg, 1 Tablet(s), Oral, At Bedtime, 90 Tablet(s), 3 Refill(s)    sertraline (sertraline 100 mg) 150 mg, 1.5 Tablet(s), Oral, Daily    spironolactone (spironolactone 50 mg, 1 Tablet(s), Oral, Daily, 90 Tablet(s), 3 Refill(s)    vitamin A (vitamin A 8000 unit 16,000 units, 2 capsule(s), Oral, Daily      Discontinued Medications  None  Physical Exam at Discharge  Vitals & Measurements  T: 36.1 °C  TMIN: 36.1 °C  TMAX: 36.8 °C  HR: 68  RR: 0  BP: 130/92  SpO2: 98%      General:  Alert, laying in bed  Eye:  PERRL. EOMI.  ENMT:  Pharynx moist, no erythema, no exudate.   Cardiovascular:  Extremities warm and well-perfused.  Respiratory:  Lungs clear to auscultation. Respirations non-labored.    Abdominal:  Soft, Nontender, Non distended.  Back:  Nontender  Extremities:  No deformities. No edema.  Skin:  Warm, dry, no rash.  Psychiatric:  Cooperative. Appropriate mood & affect.  Time Spent  Over 30 min   Follow Up Appointments     None  Nursing/Other Orders   Hospice Evaluation and Admission. 01/26/22 13:57:00 CST, Once, 01/26/22 13:57:00 CST, ALS (amyotrophic lateral sclerosis) | COVID | Respiratory distress | Shortness of breath   Regular Diet. Ordered on 01/26/22 13:57:00 CST, Meal Start Time Breakfast 0700 to 0900   Intake and Output. 01/22/22 21:24:00 CST, Continuous Order   Activity As Tolerated. 01/22/22 21:24:00 CST, Continuous Order   Code Status. Code Status Description: DNAR (Do Not Attempt Resuscitation)   Oxygen Instructions. 01/26/22 13:57:00 CST, Routine, Instructions Titrate to comfort. No O2 Saturation Monitoring. Order comment:     Addendum by MD, on February 10, 2022 10:05:46 CST (Verified)    I performed the history and examination of the patient and discussed the patient?s management with the resident on the date in the header of this document.  I reviewed the note by the resident and agree with those documented findings and plan of care.   Diagnosis List:  acute exacerbation of chronic hypoxic respiratory failure requiring non-invasive mechanical ventilation due to SARS COV2 viral pneumonia and ALS  SARS COV2 viral pneumonia (COVID 19 disease)  ALS with acute worsening  dense left upper lobe infiltrate - community acquired pneumonia - most likely aspiration  cachexia  muscle wasting  debility due to ALS  severe malnutrition  hypertension  hyperlipidemia  chronic kidney stage III  non-insulin dependent diabetes mellitus  atrial fibrillation  history of CVA  coronary artery disease