Things requiring outpatient followup:  Cardiology outpatient appointment to discuss management of heart failure, and discussing mitral valve surgery Patient would benefit from formal neuropsych evaluation regarding cognitive impairment   Admission Date: 4/7/2023 Discharge Date: 04/16/2023   Admitting Diagnoses: COVID-19  PRESENTING PROBLEM:  Chronic diastolic heart failure  Acute respiratory failure with hypoxia  Chronic atrial fibrillation with RVR  COVID-19 virus infection  COVID-19    HOSPITAL COURSE: Patient is an 86-year-old female with a long and complex past medical history presented to the emergency department earlier today with complaints of shortness of breath.  Symptoms started about 2 days ago with cough and yellow sputum she denied fevers or chest pain but when EMS arrived her oxygen saturations were in the high 80s and she was started on supplemental oxygen.  She is not normally on baseline oxygen supplementation.  She was given a DuoNeb a and brought to the emergency department for evaluation.  Workup in the emergency department demonstrated evidence of congestive heart failure and she was found to be COVID positive.  She has been fully vaccinated.  She has a history of chronic bronchitis and was treated with nebulizer with some improvement.  Patient admitted under hospitalist service for further management.  she was given remdesivir and dexamethasone.  Aggressive pulmonary toilet.  Prone as tolerated.  Repeat COVID labs done the following morning were negative.  She cannot tolerate prone position.  Remdesivir and dexamethasone were continued because of her advanced age and comorbidities.  COVID was felt to be incidental and not the underlying cause of her symptoms at this point.  Diuresis was slow with intermittent Lasix and she continued to struggle with dyspnea and peripheral edema.  She was put on a Bumex drip for more aggressive diuresis.  She did have 1 positive blood culture that grew out Staph hominis.  Patient had significant response with Bumex drip, started diuresing aggressively.  Respiratory status improved.  Mentation improved back to baseline. Patient completed 5 days of remdesivir on 04/11.  Patient's repeat blood cultures, cefazolin discontinued 4/12.  Patient lost Significant amount of weight  after diuresis.  Her Bumex drip was stopped and patient was put on home Demadex.  Regimen changed to 20 mg 2 times a day.  Patient breathing status remained stable.  Was able to come off of supplemental oxygen at rest.  She worked with Physical and Occupational therapy who recommended discharge home with assistance and 24/7 supervision.  Patient did not agree with this assessment and kept on asking why she does not qualify for rehab.  She was offered to stay at Alter care for respite care but she declined stating that she will not pay for her stay.  Patient then requested to stay inpatient till she can not arrange support at home.  Patient already had a 24 hour caregiver.  We were told by patient and is undergoing surgery and would not be able to provide assistance at home.  Patient stated that her son will be coming to stay with her.  On 4/13, case management spoke with who said he will not be coming.  Patient then asked to stay till her daughter and son-in-law came.  Inform patient that we cannot keep on delaying her discharge as from medical standpoint she has been ready for discharge.  Plan was to discharge her on 04/15 but unable to arrange home oxygen.  Patient does require 2 -3 L oxygen at night and with activity.  4/16 case management arranged home oxygen.  Patient's daughter and son-in-law also came from.  We had an extensive discussion regarding patient's recurrent hospitalization.  We informed that patient has been offered hospice care but she has refused. Understands that hospice may be appropriate and that whole family needs to sit with the patient and make a decision. Also stated that they will be looking into long-term placement has she may not be getting enough care at her home.  Patient also found to have moderate cognitive communication impairment but currently is her own person.  She makes her own decision and she wants to get discharged home and not to any other place.  She understands that if she is not compliant with medications/diet and continued drinking alcohol she will keep on having recurrent hospitalization.  Patient completed 10 days of dexamethasone on 04/16.  She was discharged home in stable condition.