Discharge Provider: DO Primary Care Provider: DO Admission Date: 10/16/2022 Discharge Date: Oct 27, 2022  PRESENTING PROBLEM: ALS (amyotrophic lateral sclerosis) (HCC) Pneumonia of both lower lobes due to infectious organism  COVID-19 virus infection  Sepsis (HCC)  COVID-19 Acute respiratory failure with hypoxia (HCC)    HOSPITAL COURSE: The patient is a 75-year-old male with a history of OSA on BiPAP, essential hypertension, prediabetes, who more recently was diagnosed with ALS in March of 2021. The patient did have dysphagia related to his ALS with placement of a PEG tube.  In September of 2022 he was admitted to hospital with massive PE.  The patient underwent thrombectomy, and was continued on anticoagulation, but had chronic respiratory failure requiring supplemental oxygen at 6 L/Min at discharge.  Patient presented to Hospital on 10/16 with increasing shortness of breath and increasing O2 requirements.  At the time of admission, CT scan of the chest showed no acute PE but did show consolidation of the left lower lobe as well as dense infiltrate in the right lower lobe and pleural effusion.  Patient was also found to be positive for COVID.  Patient was treated with broad-spectrum antibiotics, and started on dexamethasone and remdesivir.  Pulmonary was consulted virtually.  Patient was initially managed with high-flow nasal cannula and BiPAP at night.  With cefepime and vancomycin.  MRSA screen was negative and vancomycin was discontinued.  Patient was switched from cefepime to Rocephin.  Initially there was some discussion that the patient may require bronchoscopy, as there was significant mucus plugging seen on initial CT.  Patient was noted to have advanced ALS, with dysphagia, being wheelchair-bound using Hoyer lift and slide board for transfers.  Patient stated that he was adamant that he would not a tracheostomy, or chronic ventilator support.  Given the patient's wishes it was felt there was no role for bronchoscopy, with pulmonary recommending continuing antibiotics, gentle diuresis and aggressive pulmonary toilet.  Repeat CT chest was performed on 10/21 showing persistent consolidation in the left lower lobe, but clearing infiltrates in the right lower lobe.  With treatment, the patient did have a slight improvement in his respiratory status, allowing a titration of his high-flow nasal cannula.  Hospice was consulted for informational visit which occurred on 10/25/22.  By morning of 10/10/2022 decision was made to the take patient home without hospice initiation and to continue restorative care.  Long discussion had with patient, wife, his son who is a PA, about prognosis, treatment plan, supportive services that will be made available at this time.  Patient has improved his O2 support needs down to 3 L at rest, and extra O2 support has been provided in case of increased needs during mobilization up to 12 L via nasal cannula.  Repeat SLP evaluation determined that the patient is not swallowing Entocort in manner and is to be NPO except for pureed pleasure feeding infrequently.  To continue PEG tube for feedings.  Patient will have palliative Care, Home Health Care, respiratory services available at home and his daughter will also be available to provide some care support.  Patient's prognosis is guarded at this time, but patient and wife are adamant about remaining DNI.