HPI / Subjective An 85-year-old female with a past medical history significant for essential hypertension, heart failure, and severe dementia who was admitted to the ICU for symptomatic hypernatremia and acute kidney injury secondary to severe dehydration. This is hospital day 6.  No events reported overnight.  This morning she is seen resting in her hospital bed and will not attempt to interact with me once again. She holds her eyes closed and does not appear to be aware that I am in the room with her and does not attempt to look at me. She will not follow commands and does not respond to physical stimuli.  REVIEW OF SYSTEMS Patient will not attempt to answer questions.  Objective Vital Signs Dec-27-2021 0400 HR 73 RR     26 BP   124 / 77 O2Sat 99 Dec-27-2021 0000 HR 82 RR 16 BP   112 / 72 O2Sat 98 Dec-26-2021 2000 T 98.6 Dec-26-2021 1600 T 99.8 Intake and Output previous day current day encounter cumulative Intake 1933 ? 11201 Output ? ? 8 Diff (I-O) 1933 ? 11193 PHYSICAL EXAM Constitutional: Patient appears stated age, chronically ill, cachexic, and is in no acute distress at this time.  Cardiovascular: Regular rate and rhythm without murmur, gallop, or rub. No edema present in the lower extremities. Radial and dorsal pedal pulses intact 2+ bilaterally.  Respiratory: Lungs clear to auscultation bilaterally, no wheezing, no rhonchi, no rales. No accessory muscle use, no respiratory distress. Patient is currently on room air.  Gastrointestinal: Abdomen soft, non-tender. No rebound or guarding. No distension. No ascites. No organomegaly.  Psychiatric: Patient does not respond to questions or display normal affect. Appears to have poor judgment. No effort made to follow commands.  Lab Results Dec-27-2021 0625 Chemistry GLUCOSE  143BUN  52CREAT  1.0MDRD GFR  53NA  144K  3.5CL  112CALCIUM  7.9CO2  21.9OSMO  303.4ANION GP  13.6BUN/CRE  52.0MAGNESIUM  1.9PHOSPHOR  1.9 Dec-27-2021 0625 Hematology WBC  10.8RBC  3.27HGB  9.9HCT  30.6MCV  93.6MCH  30.3MCHC  32.4RDW  13.2RDWSD  45.1PLT  223MPV  12.3AUTONEU%  80.3AUTOLYM%  8.4AUTOMON%  7.3AUTOEOS%  2.2AUTOBAS%  0.4AUTONEU#  8.7AUTOLYM#  0.9AUTOMON#  0.8AUTOBAS#  0.0AUTOEOS#  0.2NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.15IG%  1.4 Procedure(s) Performed None  Active Medications POTASSIUM CHLORIDE MINIBAG 20 MEQ/ 100 ML 20 MEQ IVPB NOW 50 ML/HR PANTOPRAZOLE INJ 40 MG IVP Q24H AMINO ACID/DEXTROSE 4.25/10 % 2000 ML IV Continuous 66 ML/HR ~800 kcal per day cefTRIAXone INJ 1000 MG IV Q24H 100 ML/HR SODIUM CHLORIDE 0.9% MINIBAG+ 100 ML PLEASE ENTER INDICATION IN COMMENTS: HEPARIN 5,000 UNIT/ML 5000 UNT SUBCUT Q8H ACETAMINOPHEN 650 MG ORALLY Q4HPRN for FEVER OR MILD PAIN 1-3 ON PS max 4,000 milligrams acetaminophen per 24 hours INFLUENZA QUADRIVALENT VACCINE 0.5 ML IM ONE-UNSCHD Plan Assessment: -Severe hyponatremia secondary to a dehydration and hypovolemia, improving -Acute renal failure/insufficiency secondary to dehydration. eGFR 15 down from baseline 68 in March 2020, improving -Acute hypokalemia, persistent -Urinary tract infection with E coli sensitive to Rocephin. -Moderate dehydration -COVID-19, without respiratory failure, positive 12/15, received monocloncal antibody 12/17 -Acute delirium, secondary to the above -Moderate to severe cachexia secondary to failure to thrive and protein count malnutrition/decreased oral intake -Hypertensive urgency, resolved -Heart failure with preserved ejection fraction, EF 80% per ECHO 2017 -Moderate tricuspid regurgitation, per ECHO 2017 -Essential hypertension -Osteoarthritis -Severe dementia -Major depressive disorder  - Hypophosphatemia, 1.5 on 12/25/2021, resolved  Plan: - The Rocephin has been discontinued as the patient's UTI is treated out. - We will continue to monitor her electrolytes and renal function. - Encourage oral intake when the patient is more awake. - Anticipate discharge in the next 24 hours. - Poor prognosis.  Electronically signed on Dec-27-2021 1001 I have seen and examined the patient on this date and agree with the note as documented above and I have discussed the plan of care. Changes and additional information, if any, are documented below. I have reviewed and agree with the chief complaint, history present illness, and review of systems as documented by the resident.  Today when I am seeing the patient she is not interacting with the environment but she will try to push my hand away when I try to interact with her even do a physical exam. She is not eating, not drinking water, and as mentioned is not interactive with the environment I have reviewed and agree with the vital signs, physical exam, laboratory data as documented by the resident I have reviewed and agree with the assessment and plan of care and discussed the plan of care with the resident. I have spoken with the patient's son, who is her durable power of attorney, and he I have discussed her current condition and prognosis. He agrees that her quality of life has suffered especially after her diagnosis of COVID-19. He states that her ability to eat and drink and her mental status has rapidly decline but that she did not have good quality life before that. Him and his sister as well as his mother have all agreed that they would not want PEG tube feeding. I explained that her prognosis is grim especially since she is not interacting with the environment and not eating and drinking. He is agreeable to discharge back to the nursing home tomorrow with comfort measures and pleasure feedings if she did happen wake up. I did explain that even pleasure feedings could lead to aspiration. He understands this. Will plan for discharge tomorrow. Electronically signed