91 year old (deceased) Male.  Communication details: Call to PCP office to report patient up all night with a cough, elevated temp this morning.  Poor appetite today and fatigue. SOB, +DOE, diarrhea.  They will call the patient after speaking to the MD.  Office Visit    Family Medicine Chronic diastolic congestive heart failure +4 more  Dx Cough ? Shortness of Breath ? Insomnia ? Poor Appetite  Reason for Visit           Patient was seen today for cough, shortness of breath, insomnia and poor appetite.   Diagnoses and all orders for this visit:   Chronic diastolic congestive heart failure -     CBC and differential; Future -     B-type natriuretic peptide; Future -     Basic metabolic panel; Future -     X-ray chest 2 views; Future   Stage 3a chronic kidney disease  -     CBC and differential; Future -     B-type natriuretic peptide; Future -     Basic metabolic panel; Future   Suspected COVID-19 virus infection -     COVID-19 PCR; Future -     COVID-19 PCR   Bradycardia -     ECG 12-lead: IN OFFICE        Patient Instructions I am not entirely sure what is causing your shortness of breath.  I think it is going to turn out to be a combination of things. Your pulse is a little bit low.  EKG does not show anything that would make me insist upon a pacemaker but you do have an irregular rhythm with some "supraventricular" beats. Chest x-ray Blood work Today when you get home take an extra furosemide 20 mg pill You do not want to go to the emergency department.  If you change your mind at any time call 911   Visit time 40 minutes including obtaining history, physical exam, placing orders and, interpreting past test results, communicating to pt/family and dictating.   Daughter was a bit frustrated that he did not agree to go to the emergency department.  She thought it would be in her dad's best interest but he strongly and consistently refused emergency department evaluation.  He did say that he is dying and his time is limited even if they would elect for hospitalization   Return for Next scheduled follow up.     Patient is here with wife and daughter due to cough, shortness of breath, decreased appetite.  He is known to have interstitial lung disease, COPD, diastolic heart failure, pulmonary hypertension.  He was hospitalized a little bit over a week ago for similar symptoms.  He was felt to be in heart failure due to an elevated BNP at 503.  He was given IV Lasix but that adversely affected his kidney function.  He was transitioned and discharged to 20 mg of Lasix daily.  He is on chronic oxygen.  Since being at home he has not been doing well.  He has cough productive of clear sputum, shortness of breath and yesterday he had a fever of 100.6.   Yesterday and earlier today when we heard of his difficulties we recommended that he go to the emergency department.  He and his wife absolutely refused.  They are well aware that emergency department is the most rapid and efficient way of getting testing done.  In spite of this they wanted to come into the office to see me today.  Patient arrives in a wheelchair.  He appears to be in moderate respiratory distress.  He appears weak and frail.  I confirmed with patient and his wife their desire to return to the hospital.  They are again very clear that they do not want emergency department evaluation.  They would like for me to do what I can in the outpatient setting.   ROS:   Patient denies headache, vision changes, chest pain, chest pressure, lightheadedness, dizziness, shortness of breath at rest,  nausea, vomiting, melena, bright red blood per rectum, abdominal pain, dysuria, hematuria, focal neurologic deficit, fever, unexplained weight loss      ED to Hosp-Admission Discharged   10/6/2021 - 10/10/2021 (4 days)  Last attending ? Treatment team Severe sepsis  Principal problem Hospital Course:Patient is a 91 y.o. male  with past medical history of pulmonary fibrosis and ILD with chronic respiratory failure on home oxygen 2 L per nasal cannula, hypothyroidism, BPH, chronic diastolic heart failure was admitted to Hospital with severe sepsis secondary with associated acute on chronic respiratory failure with hypoxia secondary to COVID-19 pneumonia.  He has been undergoing treatment with dexamethasone and Remdesevir for COVID-19 pneumonia.  He did receive IV Tocilizumab treatment per ID for worsening acute on chronic respiratory failure with hypoxia requiring maxed out high flow nasal cannula oxygen.  He also required empiric antibiotics for possible superimposed community-acquired pneumonia.  Over the past 24 hours he developed worsening acute on chronic respiratory failure with hypoxia requiring maxed out high flow nasal cannula oxygen and nonrebreather.  The patient also developed worsening acute metabolic encephalopathy and end-stage agitation that did not respond to lorazepam, Zyprexa, or haloperidol.  The patient's breathing and confusion continued to worsen.  After further discussion with the patient's wife, the family has agreed to transition the patient's goals of care to comfort measures only.  The patient was seen by hospice and community care and consents were signed to transition the patient to inpatient hospice. Admission Discharged      Acute on chronic respiratory failure with hypoxia  Principal problem    Details of Hospital Stay     Presenting Problem/History of Present Illness/Reason for Admission Acute on chronic respiratory failure with hypoxia  Severe sepsis secondary to COVID-19 pneumonia Acute metabolic encephalopathy   Patient is a 91 y.o. male  with past medical history of pulmonary fibrosis and ILD with chronic respiratory failure on home oxygen 2 L per nasal cannula, hypothyroidism, BPH, chronic diastolic heart failure was admitted to Hospital with severe sepsis secondary with associated acute on chronic respiratory failure with hypoxia secondary to COVID-19 pneumonia.  He has been undergoing treatment with dexamethasone and Remdesevir for COVID-19 pneumonia.  He did receive IV Tocilizumab treatment per ID for worsening acute on chronic respiratory failure with hypoxia requiring maxed out high flow nasal cannula oxygen.  He also required empiric antibiotics for possible superimposed community-acquired pneumonia.  Over the past 24 hours he developed worsening acute on chronic respiratory failure with hypoxia requiring maxed out high flow nasal cannula oxygen and nonrebreather.  The patient also developed worsening acute metabolic encephalopathy and end-stage agitation that did not respond to lorazepam, Zyprexa, or haloperidol.  The patient's breathing and confusion continued to worsen.  After further discussion with the patient's wife, the family has agreed to transition the patient's goals of care to comfort measures only.  The patient was seen by hospice and community care and consents were signed to transition the patient to inpatient hospice.    The patient was readmitted under inpatient hospice.  He was started on continuous IV morphine infusion at 2 mg/hr. he did rest comfortably on the morphine drip and passed comfortably in the late afternoon.  The family was present at the bedside and were very grateful for the excellent care the patient had received.  All of our best wishes were offered to the family at this time.  Condition at Discharge Discharge Condition: Expired