Discharge Provider: MD Primary Care Physician at Discharge: MD Admission Date: 4/12/2023  PRESENTING PROBLEM: STEMI (ST elevation myocardial infarction) (HCC) [I21.3] Elevated troponin [R77.8] COPD exacerbation (HCC) [J44.1] Sepsis (HCC) [A41.9] Severe sepsis (HCC) [A41.9, R65.20]   HOSPITAL COURSE: Patient is a 78-year-old male with a medical history including moderate to severe aortic stenosis, hypertension, carotid stenosis, chronic obstructive pulmonary disease, hypertension, squamous cell carcinoma of the head and neck status post laryngectomy 2019 with resection February of 2023 who was admitted for shock 04/13/2023 after having 4 days of fever, chills, cough.  Patient declined to the point of needing tracheostomy on 04/14.  Patient initially on presentation did also have some EKG changes and elevation in troponin that was concerning for possible STEMI so Cardiology was consulted and performed a echocardiogram that showed no wall motion abnormalities and patient's clinical picture fit more with a type 2 demand ischemia.  Patient did also have new onset atrial fibrillation with rapid ventricular rate, so was placed on amiodarone and heparin.  Patient initially also had 2-COVID test, then had 1 positive COVID test, then had a repeat COVID test.  Unclear if patient definitely had COVID or not.  Patient also had 1/2 initial blood cultures that grew strep mitis and Streptococcus oralis but subsequently had 6 negative blood cultures as well.  Patient did also initially have a sputum culture that grew stenotrophomonas.  Patient had CTs of his chest and pelvis that revealed no intra-abdominal abnormalities, but did show right lower lobe findings concerning for pneumonia.  Patient was empirically treated with cefepime and vancomycin.  Patient's antibiotics were de-escalated after showing some improvement and has we received more cultures and a negative MRSA swab.  On 04/18, patient started to decline further so antibiotics were re-escalated due to worsening chest x-ray concerning for a new ventilator associated pneumonia.  After Infectious Disease consult, patient was placed on antibiotic regimen of minocycline and Rocephin.  Throughout the patient's stay, vasopressor requirements have continued to increase.  Patient's oxygen requirements have continued to escalate and patient has had a couple of bronchoscopies in addition to extensive antibiotic coverage.  Patient was also found to have an acute kidney injury that was worsening throughout his stay and low urine output and it was thought that volume overload could also be contributing to the patient's worsening oxygen requirements.  With Nephrology consultation, the decision was made to have the patient on CRRT.  Nursing staff did initially have difficulty placing a Foley catheter, so Urology was consulted to place a Foley.  Patient was found to have hematuria, so Urology evaluate the patient once again at bedside and after flushing the Foley removed a large blood clot and patient continued to have hematuria so patient was discontinued off of heparin.  Patient's hemoglobin did down trend and he required blood transfusion to further stabilize hemoglobin.  Despite all interventions, patient continued to require ventilation, security, increasing vasopressor requirements, and continued overall decline in function.  Infectious disease did recommend TEE and Urology was recommending cystoscopy when patient is more stable however patient continued to decline.  Extensive conversations were had with the patient's family regarding worsening clinical status and if we should pursue further interventions and workup.  The decision was made on 04/20 that the patient would prefer to go comfort care.  Date of Death: 4/20/23 Time of Death:  2:20 PM Preliminary Cause of Death: Shock