ED, Discharged , 3/13/2021 (4 hours), Hospital ED, MD Last attending o Treatment team Shortness of breath +1 more Clinical impression Chest Pain o Shortness of Breath o Dizziness Chief complaint, Patient presents with o Chest Pain, o Shortness of Breath o Dizziness. History of Present Illness , Patient is a 71 yr.. male with Hx of stage IIICM Metastatic Adenocarcinoma of the sigmoid Colon, Coronary disease, Hypertension, Dyslipidemia, Chronic Renal insufficiency, presenting to the ED with chest pain. Patient notes that he woke up this morning with pain in the right side of the chest with some associated shortness of breath. Notes symptoms. Additional information for Item 18: Notes symptoms are worse when he is up trying to exert himself and gets incredibly short of breath and fatigued. States he tried to do some workout in the garage but was unable. Denies chest pain worsening with exertion, but has been fairly constant since it began. Reports it is a dull ache. Pain is dissimilar from his previous heart attack. States he has had a mild cough, but no significant production. Denies any fevers, chills. No abnormal nausea or vomiting other than typical chemo induced side effects. Given continued issues, decided to come in for further evaluation. Review of Systems; Constitutional: Positive for fatigue. Negative for appetite change, chills, diaphoresis and fever. HENT: Negative for sore throat. Eyes: Negative for visual disturbance.  Respiratory: Positive for cough and shortness of breath. Negative for choking and chest tightness. Cardiovascular: Positive for chest pain. Negative for palpitations and leg swelling. Gastrointestinal: Positive for nausea and vomiting. Negative for abdominal pain and diarrhea. Genitourinary: Negative for dysuria. Musculoskeletal: Negative for back pain and neck pain. Skin: Negative for rash. Neurological: Positive for light-headedness. Negative for seizures, syncope, numbness and headaches. ED to Hosp-Admission, Discharged, 4/5/2021 - 4/25/2021 (20 days) Hospital, MD, Last attending Treatment team Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present. Principal problem Discharge Summary, DO (Physician), Inpatient Discharge Summary; BRIEF OVERVIEW; MD, Discharge Provider: DO, Primary Care Physician at Discharge: MD, Admission Date: 4/5/2021, Discharge Date: 4/25/2021. Discharge Diagnosis; Medical Problems ;Hospital Problems; POA, (Principal) Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present, Yes, Essential hypertension Yes, Chemotherapy-induced peripheral neuropathy, Yes. Overview Signed 5/10/2019  2:03 PM by MD, Pins and needles and numbness in tips of finger and toes, Lung metastasis Yes. Hypoxia Yes. COVID-19 Unknown, Acute respiratory failure with hypoxia Yes, Palliative care encounter Not Applicable, Declining functional status No. DETAILS OF HOSPITAL STAY; Presenting Problem/History of Present Illness/Reason for Admission, Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present. Acute hypoxemic respiratory failure due to COVID-19,Respiratory failure. Sigmoid perforation with abscess. Hospital Course; 71-year-old male prolonged admission for acute hypoxic respiratory failure secondary to COVID-19. No history of colorectal adenocarcinoma with lung mets. Prior resection of bowel, prior chemotherapy. Required management in the ICU due to worsening respiratory failure over the time that he has been admitted to Hospital (20 days). He had remained on BiPAP therapy throughout that time, received appropriate corticosteroids, and antiviral therapies. Approximately 1-1/2 weeks ago he began to develop mild left lower quadrant abdominal pain. In the last 48 hours this is significantly worsened. CT abdomen and pelvis was obtained on Friday, which displayed pneumoperitoneum, sigmoid abscess with sigmoid perforation. There is a prior anastomotic site distal to this. Given his overall complexity he was to be medically managed to avoid the need for OR and intubation.  He did well through the initial 24 hours of IV antibiotics, fluids and bowel rest. This afternoon he became increasingly dyspneic, required implementing nonrebreather mask, and subsequently developed severe rigors, tachycardia.  I obtained a stat follow-up CT scan which shows similar findings of free air within the abdomen. Given signs of impending sepsis, BiPAP therapy was initiated, bolus IV fluids were given. Blood gas, blood counts, lactic acid are pending.  He is receiving empiric Zosyn.  I discussed this with general surgery, whom is well-known to the patient. In agreement the patient likely needs surgical intervention. However given his overall complexity and in light of the fact that this area surrounds the ureter, and we do not have urology coverage. It was felt he was most appropriate to be managed in Hospital. Case was discussed with Dr. at Hospital, patient will be transferred there via air transit. At this time his blood pressure appears stable, he is tachycardia, is currently on BiPAP which will be transitioned to CPAP for transport. He has received several doses of Dilaudid, for improved pain control. No further advancement of airway was performed prior to discharge. Case was discussed with family at length, all risks and benefits of transfer were discussed with wife and patient. It is recommended to involve pulmonary critical care services including surgical ICU care as if requiring surgery he is high likelihood for prolonged vent needs. Operative Procedures Performed Treatments: See above; Procedures: Na Consults: pulmonary/intensive care and general surgery. Pertinent Test Results: CT abdomen pelvis with contrast [3279871876] (Abnormal) Resulted: 04/25/21 1811. Order Status: Completed Updated: 04/25/21 1812. Narrative: PROCEDURE INFORMATION: Exam: CT Abdomen And Pelvis With Contrast, Exam date and time: 4/25/2021 17:36, Age: 71 years old, Clinical indication: Abdominal pain; Additional info: Sepsis, bowel perf. HX of Covid19 +, malignant colon with lung metastasis. Bowel perf. TECHNIQUE: Imaging protocol: Computed tomography of the abdomen and pelvis with contrast. Radiation optimization: All CT scans at this facility use at least one of these dose optimization techniques: automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to clinical indication); or iterative reconstruction. Contrast material: 350 OMNI; Contrast volume: 80 ml; Contrast route: INTRAVENOUS (IV); COMPARISON: CT ABDOMEN PELVIS W CONTRAST 4/23/2021 16:46, FINDINGS: Tubes, catheters and devices: Catheter terminates in the right atrium in satisfactory position. Lungs: Moderate airspace opacities throughout the lung bases are similar to prior and consistent with Multilobar pneumonia consistent with the history. Liver: No hepatic masses. Gallbladder and bile ducts: Cholelithiasis. Pancreas: No ductal dilation. No masses. Spleen: No splenomegaly or focal lesions. Adrenal glands: No mass. Kidneys and ureters: 10 mm benign left renal cyst, no follow-up necessary. No renal masses or Hydronephrosis bilaterally. Stomach and bowel: Redemonstration of perforated proximal sigmoid diverticulitis. Small pneumoperitoneum is stable. Predominantly gas containing, 25 x 28 mm collection adjacent to the inflamed sigmoid colon similar to prior; a fistulous tract extends toward the midline containing gas and fluid, with suspected fistula to adjacent loops of small bowel. Moderate to severe descending and sigmoid diverticular burden. Minor right diverticular burden. No small bowel obstruction. A somewhat clumped appearance of small bowel in the right lower quadrant near the colon enteric fistula. Appendix: No evidence of appendicitis. Intraperitoneal space: Mesenteric edema around the small bowel, slightly increased, however no new mesenteric collection. There is no extravasation of enteric contrast into the collection adjacent to the sigmoid colon. Vasculature: Mild aortoiliac atherosclerosis. Lymph nodes: No significantly enlarged lymph nodes. Urinary bladder: Unremarkable as visualized. Reproductive: Unremarkable as visualized. Bones/joints: Degenerative changes in the spine. Multilevel disc space narrowing. Multilevel central canal and neuroforaminal stenosis in the lumbar spine. No acute fracture or subluxation. Soft tissues: Small fat-containing right inguinal hernia. Small fat-containing left inguinal hernia. Large ventral abdominal hernia containing gas, which has replaced the previous contents of fat and bowel loops. Volume increased compared to prior. IMPRESSION: 1. Redemonstration of perforated proximal sigmoid diverticulitis. Small pneumoperitoneum is stable. 2. Similar perisigmoid  collection; colon enteric fistula, probably at least subacute in duration. The perisigmoid collection is prominently gaseous and there is no frank abscess. 3. Suspected mild enteritis the small bowel loops or loops associated with the fistula. No obstruction. 4. Additional findings as described are similar to recent prior imaging. COMMENTS: Any incidental renal lesion less than 1 cm or classified as too small to characterize, or any incidental cystic renal lesion characterized as simple-appearing, is likely benign. No follow-up imaging is recommended for these lesions per consensus recommendations based on imaging criteria. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD, CT abdomen pelvis with contrast (Abnormal) Resulted: 04/23/21 1804, Order Status: Completed Updated: 04/23/21 1804, Addenda: THIS REPORT CONTAINS FINDINGS THAT MAY BE CRITICAL TO  PATIENT CARE. The findings were verbally communicated via telephone conference with RN at 6:03 PM EDT on 4/23/2021. The findings were acknowledged and  understood. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD Signed: 04/23/21 1804 by, MD. Narrative:  PROCEDURE INFORMATION: Exam: CT Abdomen And Pelvis With Contrast, Exam date and time: 4/23/2021 4:42 PM, Age: 71 years old  Clinical indication: Abdominal pain; Localized; Left; Additional info: HX of colon cancer. Worsening left sided  abdominal pain. HX of colon cancer. Worsening left sided abdominal pain. TECHNIQUE: Imaging protocol: Computed tomography of the abdomen and pelvis with contrast. Radiation optimization: All CT scans at this facility use at least one of these dose optimization techniques: automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to clinical indication); or iterative reconstruction. Contrast material: OMNIPAQUE 350; Contrast volume: 80 ml; Contrast route: INTRAVENOUS (IV); Other contrast: Oral, omnipaque 12mg premixed solution, 500mL pt unable to drink 1000mL; COMPARISON: 1. CT ABDOMEN PELVIS W CONTRAST 2/12/2021 11:06 AM, 2. CT ABDOMEN PELVIS W CONTRAST 11/13/2020 11:42:26 AM, 3. CT ABDOMEN PELVIS W CONTRAST 8/24/2020 10:14:40 AM, FINDINGS: Lungs: Bilateral lower lung consolidation. Liver: No mass. Gallbladder and bile ducts: Cholelithiasis, no biliary ductal dilatation. Pancreas: Normal. No ductal dilation. Spleen: Normal. No splenomegaly. Adrenal glands: Normal. No mass.  Kidneys and ureters: Normal. No hydronephrosis. Stomach and bowel: Collection of fluid and gas adjacent to the proximal sigmoid colon where there are multiple diverticuli, extraluminal gas arises from a proximal sigmoid perforation which is proximal to the sigmoid anastomosis. No bowel obstruction, no wall thickening at the anastomosis. Appendix: No evidence of appendicitis.  Intraperitoneal space: Pneumoperitoneum. Small collection of fluid and gas in the left pelvis and left lower abdomen, maximum short axis diameter approximately 2 cm, arising from the proximal sigmoid colon. Vasculature: No abdominal aortic aneurysm. Lymph nodes: No significant adenopathy. Urinary bladder: Unremarkable as visualized. Reproductive: Unremarkable as visualized. Bones/joints: No acute findings. Soft tissues: Ventral hernia containing bowel without entrapment. IMPRESSION: Perforated diverticulitis, small pericolonic abscess; the sigmoid perforation is proximal to the sigmoid anastomosis. Physical Exam at Discharge; Heart Rate: (!) 131,Resp: (!) 42, BP: (!) 168/92 Temperature: 37.1 °C (98.7 °F) Weight: 107 kg (236 lb. 12.4 oz.), General appearance: alert, appears stated age, cooperative, severe distress and morbidly obese, Head: Normocephalic, without obvious abnormality, atraumatic, Neck: supple, symmetrical, trachea midline and thyroid not enlarged, symmetric, no tenderness/mass/nodules. Lungs: retractions and diminished breath sounds Heart: tachycardia, RR. Abdomen: Distended significantly tender in the left lower quadrant with guarding throughout. Extremities: Trace pretibial, Skin: Skin color, texture, turgor normal. No rashes or lesions or Ecchymosis areas throughout upper extremities. Neurologic: Alert and oriented X 3, no focal deficit. Discharge Instructions; Condition at Discharge, Discharge Condition: critical. Admission, Discharged 4/25/2021 - 5/1/2021 (6 days) Hospital, MD, Last attending Treatment team Respiratory failure, acute. Principal problem, Discharge Summary MD (Resident) Cosigned by: MD at 5/18/2021  1:24 PM; Final Summary for Deceased Patient, BRIEF OVERVIEW; Admitting Provider: MD; Discharge Provider: MD Primary Care Physician at Discharge: MD Admission Date: 4/25/2021, Discharge Date: 5/1/2021, Final Diagnosis, Principal Problem: Respiratory failure, acute. Active Problems: Malignant neoplasm of sigmoid colon. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present COVID-19. Perforated viscus. DETAILS OF HOSPITAL STAY Presenting Problem/History of Present Illness/Reason for Admission Respiratory failure, acute, Hospital Course; Patient is a 71 yr.. male with history of metastatic colorectal adenocarcinoma with lung metastases, prior bowel resection and chemotherapy. The patient initially tested positive for Covid in early March. His symptoms at that time are mild and resolved. He was later vaccinated and that month. He started having severe symptoms again on 4/3 for which he presented to Hospital. Since that time, he has received full course of Remdesivir and steroids. He had a CT scan performed on 4/23 which revealed pneumoperitoneum secondary to presumed perforated sigmoid diverticulitis with focal sigmoid abscess. Patient was weaned down to minimal nasal cannula settings but somewhat suddenly earlier on 4/25 patient had increased work of breathing, became tachycardia, and had rigors. Hospital ordered repeat CT scan which showed similar findings in the abdomen. Patient had been maintained on Zosyn. Repeat labs were sent which were largely unremarkable. Given concerns for worsening sepsis and potential need for surgery, he was subsequently transferred Hospital. On admission to hospital, he had a normal lactic acid and no leukocytosis. He did not have evidence of peritonitis. The decision was made to treat his diverticulitis conservatively. However, early on 4/26 the patient started to develop a lactic acidosis. An extensive discussion was had with the patient and his wife regarding surgery and the possibility the patient may never be able to separate from the vent given his worsening Covid pneumonia. The patient elected to undergo an exploratory laparotomy with with segmental resection of distal descending and loop transverse colostomy. However, as the days progressed the patient had worsening respiratory status that required deep sedation, paralytics and proning all of which were unsuccessful in maintaining his oxygen saturation greater than 88%. His wife, knowing that he would not want to have a prolonged course on the ventilator, elected for transition to palliative extubating with comfort care on 4/30 and the patient expired roughly 10 minutes after extubation.