Discharge Provider: DO Primary Care Physician at Discharge: MD Admission Date: 3/24/2023  PRESENTING PROBLEM: SIRS (systemic inflammatory response syndrome) (HCC) [R65.10]   HOSPITAL COURSE:   I was called to patient?s bedside by RN to pronounce that the patient had passed.  No spontaneous movements were present. There was not response to verbal or tactile stimuli. Pupils were mid-dilated and fixed. No breath sounds were appreciated over either lung field. No carotid pulses were palpable. No heart sounds were auscultator over entire precordium.  Patient pronounced deceased at 21:15 on 4/4/23.  No family was present at bedside. RN and hospice Rn to notify family.   Patient is a 83 y.o. male with past medical history of end-stage renal disease on peritoneal dialysis, renovascular hypertension, chronic anemia, GERD, and GAD who presents today with lethargy, confusion.  History is obtained from daughter and son at bedside as patient is able to answer only a few questions (name, DOB).  The patient was recently admitted 03/15 through 3/17 with weakness and confusion.  He was found to have COVID-19.  He remained on room air and did not qualify for any medical therapy.  He was noted to have dark stools and GI was consulted for possible bleeding.  His hemoglobin remained stable and did not drop.  They felt the color of the stools was likely related to his iron supplement.  He does have baseline intermittent confusion and short-term memory difficulties.  He does continue to drive short distances and grocery shop.  His son pays his bills and his daughter does his peritoneal dialysis/cooking.  He is normally able to do his own ADLs.  She states that he has been improving since being discharged in relation to his COVID-19.  He still has a mild cough.  She states that he has had a very poor appetite ever since having COVID 19 and is barely eating.  He had an episode where he pulled on his PD tube and was placed on Keflex by his dialysis company for possible tube site infection.  This is radically improved on the Keflex.  The patient takes docusate sodium, MiraLax daily with p.r.n. lactulose for bowel movements.  His daughter states that his bowel movements the to be soft for him to have successful peritoneal dialysis.  She states that today he has had 5, black, incontinent episodes of diarrhea.  He did take lactulose, MiraLax and docusate sodium yesterday.  The patient is not complaining of any abdominal pain.  She states that he did have some retching when he had episode of diarrhea as it was quite odorous and mucous-like.  Family does note that they have noticed that he is a bit more confused at night at baseline.  The patient's son at bedside states that he has noticed him being very fidgety and somewhat hard to arouse at night.  His daughter states that he has been taking Xanax for years.  He is prescribed 0.25 mg to take 2 times a day, however he has always taken 0.5 nightly only.   In the ER the patient was febrile with a temperature of 38.4° C, hypotensive with a blood pressure of 101/52, respiratory rate 24, tachycardic with a pulse of 108. Labs significant for potassium 3.3, anion gap 21, BUN 104, creatinine 7.42, AST 54, ALT 41, lactic acid 2.8-- >1.2, WBC 11.8, hemoglobin 11.8, UA with protein, 1 WBC, <1 RBC.  CXR with cardiomegaly and interstitial prominence which could reflect mild edema or atypical infection.  Slightly increased density in the right midlung zone peripherally favored to represent artifact from the chest wall soft tissues, less likely infiltrate.  Blood cultures were collected.  The patient was given 2 L of IV fluid.  He was given 1 g of IV Tylenol.