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This is VAERS ID 1105820

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1105820
VAERS Form:2
Age:89.0
Sex:Female
Location:Wisconsin
Vaccinated:2021-02-12
Onset:2021-02-14
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Acute myocardial infarction, Acute respiratory distress syndrome, Acute respiratory failure, Alanine aminotransferase normal, Albumin globulin ratio normal, Anion gap, Aspartate aminotransferase normal, Basophil count decreased, Blood albumin decreased, Blood alkaline phosphatase normal, Blood bicarbonate decreased, Blood bilirubin normal, Blood calcium decreased, Blood chloride normal, Blood creatinine increased, Blood culture, Blood glucose increased, Blood lactic acid increased, Blood pH increased, Blood potassium normal, Blood pressure decreased, Blood sodium decreased, Blood urea increased, Bradycardia, C-reactive protein increased, Carbon dioxide decreased, Cardiac arrest, Chest X-ray abnormal, Cyanosis, Death, Differential white blood cell count abnormal, Dyspnoea, Echocardiogram, Electrocardiogram abnormal, Electrocardiogram QT prolonged, Electrocardiogram T wave peaked, Eosinophil count normal, Fibrin D dimer increased, Full blood count abnormal, Globulin, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Haemoptysis, Leukocytosis, Lung infiltration, Lymphocyte count decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased, Mean cell volume increased, Metabolic acidosis, Monocyte count, Myocardial ischaemia, Neutrophil count increased, Oxygen saturation decreased, PCO2 decreased, Platelet count decreased, Pneumonia, PO2 decreased, Protein total normal, Pulse absent, Respiratory alkalosis, Sepsis, Septic shock, Tachypnoea, White blood cell count, General physical health deterioration, Mean platelet volume, Neutrophil percentage increased, Lymphocyte percentage decreased, Continuous positive airway pressure, Red cell distribution width normal, Mean platelet volume normal, Troponin increased, Troponin T increased, Venipuncture, Eosinophil percentage, Basophil percentage, Monocyte percentage, Base excess negative, Blood electrolytes normal, Procalcitonin increased, Mechanical ventilation, Acute kidney injury, Respiratory symptom, Multiple organ dysfunction syndrome, SARS-CoV-2 test negative, SARS-CoV-2 test, Suspected COVID-19, Agonal respiration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Rivaroxaban 15 and 20 MG, Tylenol, Meclizine 25 MG; Aspirin 18 MG daily, Pravastatin 20 MG daily, Multivitamins, BP formulation, Norvasc 5mg tablet daily . atenolol 25MG tablet daily
Current Illness: none
Preexisting Conditions: Abdominal Aortic Anuerysm, Atypical chest pain, Benign essential Hypertension, Pure hypercholesterolemia
Allergies: none
Diagnostic Lab Data: Diagnostics: Results for orders placed or performed during the hospital encounter of 02/14/21 CBC WITH DIFFERENTIAL Result Value Ref Range White Blood Cells 10.8 3.8 - 10.8 K/uL Red Blood Cells 3.94 (L) 4.33 - 5.75 M/uL Hemoglobin 13.0 (L) 13.4 - 17.6 g/dL Hematocrit 38.0 (L) 38.2 - 50.2 % MCV 96.4 (H) 82 - 96 fL MCH 33.0 (H) 28.0 - 32.8 pg MCHC 34.2 32.4 - 35.7 g/dL RDW 13.2 11.2 - 15.6 % Platelet Count 131 (L) 140 - 390 K/uL MPV 9.4 6.7 - 10.6 fL Neutrophil % 91.2 % Lymphocyte % 1.7 % Monocyte % 6.8 % Eosinophil % 0.0 % Basophil % 0.3 % Absolute Neutrophils 9.8 (H) 1.8 - 7.1 K/uL Absolute Lymphocytes 0.2 (L) 0.9 - 3.5 K/uL Absolute Monocytes 0.7 0.2 - 0.9 K/uL Absolute Eosinophils 0.0 0.0 - 0.5 K/uL Absolute Basophils 0.0 0.0 - 0.2 K/uL COMPREHENSIVE METABOLIC PANEL Result Value Ref Range Sodium 135 133 - 144 mEq/L Potassium 4.8 3.5 - 5.0 mEq/L Chloride 103 95 - 107 mEq/L Carbon Dioxide 22 22 - 32 mEq/L Anion Gap 10 6 - 15 mEq/L BUN 38 (H) 8 - 24 mg/dL Creatinine 1.41 (H) 0.50 - 1.30 mg/dL Glomerular Filt Rate 44 (L) $g60 mL/min Glucose 164 (H) 70 - 100 mg/dL Albumin 3.4 (L) 3.5 - 5.2 g/dL Calcium 8.5 (L) 8.6 - 10.4 mg/dL AST 39 11 - 41 IU/L ALT 14 11 - 66 IU/L Alkaline Phosphatase 51 35 - 121 IU/L Bilirubin, Total 0.9 <1.5 mg/dL Total Protein 6.6 6.2 - 8.5 g/dL Globulin 3.2 1.8 - 3.7 g/dL A:G Ratio 1.1 (L) 1.2 - 2.7 TROPONIN T, HIGH SENSITIVITY Result Value Ref Range Troponin, High Sensitivity 176 (HH) <12 ng/L PROCALCITONIN Result Value Ref Range Procalcitonin 0.36 (H) <0.25 ng/mL COVID (SARS-COV-2) BY RAPID ANTIGEN Result Value Ref Range COVID-19 Antigen Not detected NOTD TROPONIN T, HIGH SENSITIVITY Result Value Ref Range Troponin, High Sensitivity 233 (HH) <12 ng/L LACTIC ACID Result Value Ref Range Lactate 2.5 (H) 0.4 - 2.0 mmol/L CRP C REACTIVE PROTEIN QUANT Result Value Ref Range C Reactive Protein, Quantitative 7.34 (H) <0.80 mg/dL COVID AG DIRECT OPTICAL BILL Result Value Ref Range CPT 87811 Covid Antigen Direct Bill Billed for services performed D-DIMER Result Value Ref Range D-dimer 0.53 (H) <0.50 ug/mL FEU ARTERIAL BLOOD GAS Result Value Ref Range Patient Oxygen 100% pH, Arterial 7.46 (H) 7.35 - 7.45 pCO2, Arterial 29 (L) 30 - 45 mmHg pO2, Arterial 54 (L) 75 - 95 mmHg Base Deficit 2 0 - 2 Oxygen Saturation, Arterial 87 (L) 95 - 98 % Bicarbonate, Arterial 20 (L) 22 - 26 mmol/L Specimen type Arterial TCO2, Arterial 21 20 - 30 mEq/L Allens Test ALLENS TEST OK EKG (HOSPITAL) Result Value Ref Range Systolic BP 107 mmHg Diastolic BP 56 mmHg Ventricular Rate 82 BPM Atrial Rate 82 BPM QRS Duration 100 ms Q-T Interval 394 ms QTC Calculation(Bezet) 460 ms Calculated R Axis 17 degrees Calculated T Axis 45 degrees Diagnosis Accelerated Junctional rhythm Nonspecific ST and T wave abnormality Prolonged QT interval or tu fusion, consider myocardial disease, electrolyte imbalance, or drug effects Abnormal ECG When compared with ECG of 10-NOV-2020 10:24, Junctional rhythm has replaced Sinus rhythm Vent. rate has increased BY 30 BPM ST now depressed in Anterior leads CULTURE, BLOOD. Specimen: BLOOD Result Value Ref Range Specimen Description BLOOD 10 mL each bottle Drawn from Left Antecubital area. Venipuncture Culture Pending Report Status Pending CULTURE, BLOOD. Specimen: BLOOD Result Value Ref Range Specimen Description BLOOD 10 mL each bottle Venipuncture Drawn from Left Antecubital area. Culture Pending Report Status Pending Medical Decision Making: Patient is an 89-year-old male who presents emergency department for evaluation of shortness of breath and cough. Differential diagnosis includes, but is not limited to, acute coronary syndrome, pneumonia, pulmonary embolism, reaction from recent COVID-19 vaccine, COVID-19 infection, other viral upper respiratory infection, pleural effusion, or CHF. The patient denies any discrete chest pain at this time, though he has had some chest pain with exertion for the past 6 months. He has had shortness of breath along with his cough, increasing my suspicion for possible infectious process. Upon his arrival, the patient is known to be tachypneic, with normal oxygen saturation rates. He is not tachycardic or febrile, therefore does not meet SIRS criteria at this time. Plan at this time to obtain laboratory evaluations, chest x-ray, and EKG. Low threshold to broaden evaluations to include infectious workup. Please reference the remaining ED Course for further assessment, plan, and disposition documentation. ED Course as of Feb 14 1916 Sun Feb 14, 2021 1230 EKG reveals sinus rhythm at a rate of 82 beats per minute. QRS duration 100 milliseconds. QTC slightly prolonged at 460 milliseconds. There is somewhat concerning peaked T-waves in leads V2 and V3 along with with possible ST elevation in lead V1 this does represent a change from the patient''s previous study in November, 2020. EKG (Hospital) 1315 No leukocytosis. Hemoglobin and hematocrit within normal limits for the patient. No thrombocytopenia. Slight elevation in absolute neutrophil count. CBC (Complete Blood Count) With Differential(!) 1330 Elevated at 176. As the patient has been having pain for the past 2 days, I am uncertain if this is catching the increase in his troponin, or the downtrend. He continues to deny chest pain and has reported that his shortness of breath has resolved. TROPONIN T, HIGH SENSITIVITY(!!) 1419 Electrolytes within normal limits. Creatinine elevated at 1.41, though this is not significantly elevated in comparison to study obtained approximately 3 weeks ago at 1.2. Liver function tests within normal limits. No anion gap. Comprehensive Metabolic Panel(!) 1420 By my interpretation, multifocal bilateral infiltrates, most consistent with COVID-19. Also possible right middle lobe infiltrate, concerning for possible superimposed bacterial pneumonia. This is interesting as the patient did just receive his 2nd COVID-19 vaccine. Plan at this time to broaden infectious work up and order for the patient to receive empiric antibiotics. XR Chest 1V Portable 1437 Elevated at 2.5. I will provide the patient with another fluid bolus as his IVC does appear flat upon ultrasound. Lactic Acid(!) 1503 Continues elevated 233. Will consult cardiology. TROPONIN T, HIGH SENSITIVITY(!!) 1506 IMPRESSION: 1. Significant and concerning patchy airspace opacities of the right upper, right lower and left mid lung, concerning for a pneumonic process. Less likely, viral upper is for infection, including Covid 19, could be present. 2. No other etiology seen for symptoms S: 2/14/2021 14:45 CST Electronically Authenticated D: 2/14/2021 14:42 CST XR Chest 1V Portable 1506 I did have a discussion with the patient''s daughter regarding which she believes her father''s code status is. She agrees that he is likely DNR DNI, but does think that he would like to have the cardiac catheterization completed. I will confirm this with the patient. 1617 Patient noted to become hypoxic to 76%. Borderline hypotensive at 91/55. No associated tachycardia. Slightly tachypneic at 26 br/min. Oxygen increased to 15 L/min and RT paged for BiPAP. After a discussion with the patient, he endorses that he understands what DNR/DNI status means, as his wife recently passed away approximately five months ago. He does share that he wishes to be DNR/DNI, which he believes he has paperwork reflecting. I believe at this time that he is of sound mind to make this decision as well, should we not have paperwork available to us reinforce this. He does request that I contact his daughter. 1621 Bedside cardiac ultrasound does not reveal pericardial effusion. IVC appears flat. Will order for the patient receive a 2nd 500 cubic centimeters bolus. RT is present at the bedside Redding to place NIPPV. 1704 D-dimer does age adjust within normal limit. D-DIMER(!) 1705 Patient with acute primary respiratory alkalosis with secondary metabolic acidosis. Continues to be hypoxic on 100% FiO2 with saturation rates at 89%. At this point in time, I favor the patient''s NSTEMI is secondary to demand ischemia given his ongoing hypoxia. However, given his previous reported history of exertional chest discomfort and dyspnea on exertion, I will at least discuss the patient with another Hospital. ARTERIAL BLOOD GAS(!) 1805 Patient did have a significant desaturation event that resulted after he disconnected himself from NIPPV. Upon my arrival into the room, he was noted to be setting 8% with good waveform. He was cyanotic with agonal respirations. He was noted to have a pulse that corresponded with the monitor at a tachycardic rate. He was rapidly placed in a supine position and of bagged with a non-rebreather to increase his oxygen saturation rates. His oxygen saturation rate did increase, but has not completely recovered. We did bag him for several minutes and his oxygen level is now in the low 80s. He is currently on non-rebreather at 15 liters/minute. He is not following commands. His daughter is present and I did advise her of this recent update. I did speak to another Hospital and inform them that the patient would not be transferred at this time. Patient''s blood pressure is noted to be 124/73 mmHg, therefore I will order him some morphine for air hunger. I did brief the patient''s daughter on his current status and we will have her be present in the room with him. 1851 Patient continued to deteriorate, ultimately coughing up bloody secretions. He was suctioned, but continued to be tachypneic and have increased work of breathing. He became bradycardic with heart rates in the 30s. After a discussion with the patient''s daughter, the decision was made to silence alarms. Patient was accompanied by his daughter, ultimately noted to lose pulses and time of death was called at 1830, confirmed by loss of palpable pulses and lose of auscultated pulses. Time was spent discussing the patient with his daughter. We did expedite his PCR COVID swab so as to ultimately know his COVID-19 status. We did offer to contact additionally family members on the behalf of the patient''s family.
CDC 'Split Type':

Write-up: Patient seen and evaluated by PA-C. with myself. We agreed on the clinical findings and implemented our plan together. Please see PA''s note for details. All relevant procedures supervised. Patient arrived to the emergency department due to respiratory symptoms, hypoxic, reported that Wednesday he received his 2nd dose of COVID vaccine. His initial workup was concern for NSTEMI with elevated troponin and peaked T-waves, his chest x-ray concerning for COVID/pneumonia. Patient initially tolerated oxygen by nasal cannula and sepsis protocol was started including IV fluid resuscitation that was done cautiously due to the concern of COVID with respiratory failure. The biotics were given. PA-C readdressed code status with patient who confirmed that his DNR DNI, she so contacted his daughter. Patient had multiorgan failure including acute kidney injury, and pneumonia with respiratory failure +/- respiratory failure. Due to the concern of NSTEMI patient was initially going to be transfer to was hospital and transfer was started. Patient respiratory status started deteriorating and his blood pressure dropped slightly but improved after 500 cubic centimeters of IV fluid and he was also placed on a NIPPV. Around 6:00 p.m. patient has significantly desaturation and he discontinued himself NIPPV. Due to inability to intubate patient, he was ventilated with BVM, patient is slowly improved saturation levels and was opening his eyes, he was placed on a non-rebreather. At this point there is high concern of ARDS and due to inability to intubate or give for the respiratory support His daughter was at bedside and updated of current medical status and poor prognosis. Patient continued deteriorating and at this point he had agonal breathing. His daughter was at bedside and she was made aware of the futile prognosis of patient due to his respiratory failure. Patient rapidly became bradycardic and went into cardiac arrest. No CPR was done due to the DNI DNR status of the patient. ? Critical Care Procedure Note Authorized and Performed by: MD Total critical care time: Approximately 30 minutes Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient''s response to treatment; frequent reassessment; and, discussions with other providers. This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see MDM section and the rest of the note for further information on patient assessment and treatment. ? PE: VITAL SIGNS: BP: 126/75 Pulse: (!) 122 Resp: (!) 40 SpO2: (!) 82 % Temp: 98.1 ?F (36.7 ?C) Height: 5'' 8" (172.7 cm) Weight: 152 lb (68.9 kg) General: Alert, nontoxic, in no acute distress. Lungs: Clear to auscultation bilaterally. ? CLINICAL IMPRESSION: 1. Sepsis with acute hypoxic respiratory failure and septic shock, due to unspecified organism (HCC) 2. Suspected COVID-19 virus infection 3. NSTEMI (non-ST elevated myocardial infarction) (HCC) 4. Multifocal pneumonia 5. ARDS (adult respiratory distress syndrome) (HCC) 6. Acute kidney injury (HCC) ? ? Further care and disposition otherwise as outlined by PA. ? ? ED on 2/14/2021 Revision & Routing History Detailed Report Note filed date Mon Feb 15, 2021 ?8:46 AM


Changed on 5/7/2021

VAERS ID: 1105820 Before After
VAERS Form:2
Age:89.0
Sex:Female
Location:Wisconsin
Vaccinated:2021-02-12
Onset:2021-02-14
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Acute myocardial infarction, Acute respiratory distress syndrome, Acute respiratory failure, Alanine aminotransferase normal, Albumin globulin ratio normal, Anion gap, Aspartate aminotransferase normal, Basophil count decreased, Blood albumin decreased, Blood alkaline phosphatase normal, Blood bicarbonate decreased, Blood bilirubin normal, Blood calcium decreased, Blood chloride normal, Blood creatinine increased, Blood culture, Blood glucose increased, Blood lactic acid increased, Blood pH increased, Blood potassium normal, Blood pressure decreased, Blood sodium decreased, Blood urea increased, Bradycardia, C-reactive protein increased, Carbon dioxide decreased, Cardiac arrest, Chest X-ray abnormal, Cyanosis, Death, Differential white blood cell count abnormal, Dyspnoea, Echocardiogram, Electrocardiogram abnormal, Electrocardiogram QT prolonged, Electrocardiogram T wave peaked, Eosinophil count normal, Fibrin D dimer increased, Full blood count abnormal, Globulin, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Haemoptysis, Leukocytosis, Lung infiltration, Lymphocyte count decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased, Mean cell volume increased, Metabolic acidosis, Monocyte count, Myocardial ischaemia, Neutrophil count increased, Oxygen saturation decreased, PCO2 decreased, Platelet count decreased, Pneumonia, PO2 decreased, Protein total normal, Pulse absent, Respiratory alkalosis, Sepsis, Septic shock, Tachypnoea, White blood cell count, General physical health deterioration, Mean platelet volume, Neutrophil percentage increased, Lymphocyte percentage decreased, Continuous positive airway pressure, Red cell distribution width normal, Mean platelet volume normal, Troponin increased, Troponin T increased, Venipuncture, Eosinophil percentage, Basophil percentage, Monocyte percentage, Base excess negative, Blood electrolytes normal, Procalcitonin increased, Mechanical ventilation, Acute kidney injury, Respiratory symptom, Multiple organ dysfunction syndrome, SARS-CoV-2 test negative, SARS-CoV-2 test, Suspected COVID-19, Agonal respiration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Rivaroxaban 15 and 20 MG, Tylenol, Meclizine 25 MG; Aspirin 18 MG daily, Pravastatin 20 MG daily, Multivitamins, BP formulation, Norvasc 5mg tablet daily . atenolol 25MG tablet daily
Current Illness: none
Preexisting Conditions: Abdominal Aortic Anuerysm, Atypical chest pain, Benign essential Hypertension, Pure hypercholesterolemia
Allergies: none none
Diagnostic Lab Data: Diagnostics: Results for orders placed or performed during the hospital encounter of 02/14/21 CBC WITH DIFFERENTIAL Result Value Ref Range White Blood Cells 10.8 3.8 - 10.8 K/uL Red Blood Cells 3.94 (L) 4.33 - 5.75 M/uL Hemoglobin 13.0 (L) 13.4 - 17.6 g/dL Hematocrit 38.0 (L) 38.2 - 50.2 % MCV 96.4 (H) 82 - 96 fL MCH 33.0 (H) 28.0 - 32.8 pg MCHC 34.2 32.4 - 35.7 g/dL RDW 13.2 11.2 - 15.6 % Platelet Count 131 (L) 140 - 390 K/uL MPV 9.4 6.7 - 10.6 fL Neutrophil % 91.2 % Lymphocyte % 1.7 % Monocyte % 6.8 % Eosinophil % 0.0 % Basophil % 0.3 % Absolute Neutrophils 9.8 (H) 1.8 - 7.1 K/uL Absolute Lymphocytes 0.2 (L) 0.9 - 3.5 K/uL Absolute Monocytes 0.7 0.2 - 0.9 K/uL Absolute Eosinophils 0.0 0.0 - 0.5 K/uL Absolute Basophils 0.0 0.0 - 0.2 K/uL COMPREHENSIVE METABOLIC PANEL Result Value Ref Range Sodium 135 133 - 144 mEq/L Potassium 4.8 3.5 - 5.0 mEq/L Chloride 103 95 - 107 mEq/L Carbon Dioxide 22 22 - 32 mEq/L Anion Gap 10 6 - 15 mEq/L BUN 38 (H) 8 - 24 mg/dL Creatinine 1.41 (H) 0.50 - 1.30 mg/dL Glomerular Filt Rate 44 (L) $g60 mL/min Glucose 164 (H) 70 - 100 mg/dL Albumin 3.4 (L) 3.5 - 5.2 g/dL Calcium 8.5 (L) 8.6 - 10.4 mg/dL AST 39 11 - 41 IU/L ALT 14 11 - 66 IU/L Alkaline Phosphatase 51 35 - 121 IU/L Bilirubin, Total 0.9 <1.5 mg/dL Total Protein 6.6 6.2 - 8.5 g/dL Globulin 3.2 1.8 - 3.7 g/dL A:G Ratio 1.1 (L) 1.2 - 2.7 TROPONIN T, HIGH SENSITIVITY Result Value Ref Range Troponin, High Sensitivity 176 (HH) <12 ng/L PROCALCITONIN Result Value Ref Range Procalcitonin 0.36 (H) <0.25 ng/mL COVID (SARS-COV-2) BY RAPID ANTIGEN Result Value Ref Range COVID-19 Antigen Not detected NOTD TROPONIN T, HIGH SENSITIVITY Result Value Ref Range Troponin, High Sensitivity 233 (HH) <12 ng/L LACTIC ACID Result Value Ref Range Lactate 2.5 (H) 0.4 - 2.0 mmol/L CRP C REACTIVE PROTEIN QUANT Result Value Ref Range C Reactive Protein, Quantitative 7.34 (H) <0.80 mg/dL COVID AG DIRECT OPTICAL BILL Result Value Ref Range CPT 87811 Covid Antigen Direct Bill Billed for services performed D-DIMER Result Value Ref Range D-dimer 0.53 (H) <0.50 ug/mL FEU ARTERIAL BLOOD GAS Result Value Ref Range Patient Oxygen 100% pH, Arterial 7.46 (H) 7.35 - 7.45 pCO2, Arterial 29 (L) 30 - 45 mmHg pO2, Arterial 54 (L) 75 - 95 mmHg Base Deficit 2 0 - 2 Oxygen Saturation, Arterial 87 (L) 95 - 98 % Bicarbonate, Arterial 20 (L) 22 - 26 mmol/L Specimen type Arterial TCO2, Arterial 21 20 - 30 mEq/L Allens Test ALLENS TEST OK EKG (HOSPITAL) Result Value Ref Range Systolic BP 107 mmHg Diastolic BP 56 mmHg Ventricular Rate 82 BPM Atrial Rate 82 BPM QRS Duration 100 ms Q-T Interval 394 ms QTC Calculation(Bezet) 460 ms Calculated R Axis 17 degrees Calculated T Axis 45 degrees Diagnosis Accelerated Junctional rhythm Nonspecific ST and T wave abnormality Prolonged QT interval or tu fusion, consider myocardial disease, electrolyte imbalance, or drug effects Abnormal ECG When compared with ECG of 10-NOV-2020 10:24, Junctional rhythm has replaced Sinus rhythm Vent. rate has increased BY 30 BPM ST now depressed in Anterior leads CULTURE, BLOOD. Specimen: BLOOD Result Value Ref Range Specimen Description BLOOD 10 mL each bottle Drawn from Left Antecubital area. Venipuncture Culture Pending Report Status Pending CULTURE, BLOOD. Specimen: BLOOD Result Value Ref Range Specimen Description BLOOD 10 mL each bottle Venipuncture Drawn from Left Antecubital area. Culture Pending Report Status Pending Medical Decision Making: Patient is an 89-year-old male who presents emergency department for evaluation of shortness of breath and cough. Differential diagnosis includes, but is not limited to, acute coronary syndrome, pneumonia, pulmonary embolism, reaction from recent COVID-19 vaccine, COVID-19 infection, other viral upper respiratory infection, pleural effusion, or CHF. The patient denies any discrete chest pain at this time, though he has had some chest pain with exertion for the past 6 months. He has had shortness of breath along with his cough, increasing my suspicion for possible infectious process. Upon his arrival, the patient is known to be tachypneic, with normal oxygen saturation rates. He is not tachycardic or febrile, therefore does not meet SIRS criteria at this time. Plan at this time to obtain laboratory evaluations, chest x-ray, and EKG. Low threshold to broaden evaluations to include infectious workup. Please reference the remaining ED Course for further assessment, plan, and disposition documentation. ED Course as of Feb 14 1916 Sun Feb 14, 2021 1230 EKG reveals sinus rhythm at a rate of 82 beats per minute. QRS duration 100 milliseconds. QTC slightly prolonged at 460 milliseconds. There is somewhat concerning peaked T-waves in leads V2 and V3 along with with possible ST elevation in lead V1 this does represent a change from the patient''s previous study in November, 2020. EKG (Hospital) 1315 No leukocytosis. Hemoglobin and hematocrit within normal limits for the patient. No thrombocytopenia. Slight elevation in absolute neutrophil count. CBC (Complete Blood Count) With Differential(!) 1330 Elevated at 176. As the patient has been having pain for the past 2 days, I am uncertain if this is catching the increase in his troponin, or the downtrend. He continues to deny chest pain and has reported that his shortness of breath has resolved. TROPONIN T, HIGH SENSITIVITY(!!) 1419 Electrolytes within normal limits. Creatinine elevated at 1.41, though this is not significantly elevated in comparison to study obtained approximately 3 weeks ago at 1.2. Liver function tests within normal limits. No anion gap. Comprehensive Metabolic Panel(!) 1420 By my interpretation, multifocal bilateral infiltrates, most consistent with COVID-19. Also possible right middle lobe infiltrate, concerning for possible superimposed bacterial pneumonia. This is interesting as the patient did just receive his 2nd COVID-19 vaccine. Plan at this time to broaden infectious work up and order for the patient to receive empiric antibiotics. XR Chest 1V Portable 1437 Elevated at 2.5. I will provide the patient with another fluid bolus as his IVC does appear flat upon ultrasound. Lactic Acid(!) 1503 Continues elevated 233. Will consult cardiology. TROPONIN T, HIGH SENSITIVITY(!!) 1506 IMPRESSION: 1. Significant and concerning patchy airspace opacities of the right upper, right lower and left mid lung, concerning for a pneumonic process. Less likely, viral upper is for infection, including Covid 19, could be present. 2. No other etiology seen for symptoms S: 2/14/2021 14:45 CST Electronically Authenticated D: 2/14/2021 14:42 CST XR Chest 1V Portable 1506 I did have a discussion with the patient''s daughter regarding which she believes her father''s code status is. She agrees that he is likely DNR DNI, but does think that he would like to have the cardiac catheterization completed. I will confirm this with the patient. 1617 Patient noted to become hypoxic to 76%. Borderline hypotensive at 91/55. No associated tachycardia. Slightly tachypneic at 26 br/min. Oxygen increased to 15 L/min and RT paged for BiPAP. After a discussion with the patient, he endorses that he understands what DNR/DNI status means, as his wife recently passed away approximately five months ago. He does share that he wishes to be DNR/DNI, which he believes he has paperwork reflecting. I believe at this time that he is of sound mind to make this decision as well, should we not have paperwork available to us reinforce this. He does request that I contact his daughter. 1621 Bedside cardiac ultrasound does not reveal pericardial effusion. IVC appears flat. Will order for the patient receive a 2nd 500 cubic centimeters bolus. RT is present at the bedside Redding to place NIPPV. 1704 D-dimer does age adjust within normal limit. D-DIMER(!) 1705 Patient with acute primary respiratory alkalosis with secondary metabolic acidosis. Continues to be hypoxic on 100% FiO2 with saturation rates at 89%. At this point in time, I favor the patient''s NSTEMI is secondary to demand ischemia given his ongoing hypoxia. However, given his previous reported history of exertional chest discomfort and dyspnea on exertion, I will at least discuss the patient with another Hospital. ARTERIAL BLOOD GAS(!) 1805 Patient did have a significant desaturation event that resulted after he disconnected himself from NIPPV. Upon my arrival into the room, he was noted to be setting 8% with good waveform. He was cyanotic with agonal respirations. He was noted to have a pulse that corresponded with the monitor at a tachycardic rate. He was rapidly placed in a supine position and of bagged with a non-rebreather to increase his oxygen saturation rates. His oxygen saturation rate did increase, but has not completely recovered. We did bag him for several minutes and his oxygen level is now in the low 80s. He is currently on non-rebreather at 15 liters/minute. He is not following commands. His daughter is present and I did advise her of this recent update. I did speak to another Hospital and inform them that the patient would not be transferred at this time. Patient''s blood pressure is noted to be 124/73 mmHg, therefore I will order him some morphine for air hunger. I did brief the patient''s daughter on his current status and we will have her be present in the room with him. 1851 Patient continued to deteriorate, ultimately coughing up bloody secretions. He was suctioned, but continued to be tachypneic and have increased work of breathing. He became bradycardic with heart rates in the 30s. After a discussion with the patient''s daughter, the decision was made to silence alarms. Patient was accompanied by his daughter, ultimately noted to lose pulses and time of death was called at 1830, confirmed by loss of palpable pulses and lose of auscultated pulses. Time was spent discussing the patient with his daughter. We did expedite his PCR COVID swab so as to ultimately know his COVID-19 status. We did offer to contact additionally family members on the behalf of the patient''s family.
CDC 'Split Type':

Write-up: Patient seen and evaluated by PA-C. with myself. We agreed on the clinical findings and implemented our plan together. Please see PA''s note for details. All relevant procedures supervised. Patient arrived to the emergency department due to respiratory symptoms, hypoxic, reported that Wednesday he received his 2nd dose of COVID vaccine. His initial workup was concern for NSTEMI with elevated troponin and peaked T-waves, his chest x-ray concerning for COVID/pneumonia. Patient initially tolerated oxygen by nasal cannula and sepsis protocol was started including IV fluid resuscitation that was done cautiously due to the concern of COVID with respiratory failure. The biotics were given. PA-C readdressed code status with patient who confirmed that his DNR DNI, she so contacted his daughter. Patient had multiorgan failure including acute kidney injury, and pneumonia with respiratory failure +/- respiratory failure. Due to the concern of NSTEMI patient was initially going to be transfer to was hospital and transfer was started. Patient respiratory status started deteriorating and his blood pressure dropped slightly but improved after 500 cubic centimeters of IV fluid and he was also placed on a NIPPV. Around 6:00 p.m. patient has significantly desaturation and he discontinued himself NIPPV. Due to inability to intubate patient, he was ventilated with BVM, patient is slowly improved saturation levels and was opening his eyes, he was placed on a non-rebreather. At this point there is high concern of ARDS and due to inability to intubate or give for the respiratory support His daughter was at bedside and updated of current medical status and poor prognosis. Patient continued deteriorating and at this point he had agonal breathing. His daughter was at bedside and she was made aware of the futile prognosis of patient due to his respiratory failure. Patient rapidly became bradycardic and went into cardiac arrest. No CPR was done due to the DNI DNR status of the patient. ? Critical Care Procedure Note Authorized and Performed by: MD Total critical care time: Approximately 30 minutes Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient''s response to treatment; frequent reassessment; and, discussions with other providers. This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see MDM section and the rest of the note for further information on patient assessment and treatment. ? PE: VITAL SIGNS: BP: 126/75 Pulse: (!) 122 Resp: (!) 40 SpO2: (!) 82 % Temp: 98.1 ?F F (36.7 ?C) C) Height: 5'' 8" (172.7 cm) Weight: 152 lb (68.9 kg) General: Alert, nontoxic, in no acute distress. Lungs: Clear to auscultation bilaterally. ? CLINICAL IMPRESSION: 1. Sepsis with acute hypoxic respiratory failure and septic shock, due to unspecified organism (HCC) 2. Suspected COVID-19 virus infection 3. NSTEMI (non-ST elevated myocardial infarction) (HCC) 4. Multifocal pneumonia 5. ARDS (adult respiratory distress syndrome) (HCC) 6. Acute kidney injury (HCC) ? ? Further care and disposition otherwise as outlined by PA. ? ? ED on 2/14/2021 Revision & Routing History Detailed Report Note filed date Mon Feb 15, 2021 ?8:46 8:46 AM


Changed on 5/14/2021

VAERS ID: 1105820 Before After
VAERS Form:2
Age:89.0
Sex:Female
Location:Wisconsin
Vaccinated:2021-02-12
Onset:2021-02-14
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Acute myocardial infarction, Acute respiratory distress syndrome, Acute respiratory failure, Alanine aminotransferase normal, Albumin globulin ratio normal, Anion gap, Aspartate aminotransferase normal, Basophil count decreased, Blood albumin decreased, Blood alkaline phosphatase normal, Blood bicarbonate decreased, Blood bilirubin normal, Blood calcium decreased, Blood chloride normal, Blood creatinine increased, Blood culture, Blood glucose increased, Blood lactic acid increased, Blood pH increased, Blood potassium normal, Blood pressure decreased, Blood sodium decreased, Blood urea increased, Bradycardia, C-reactive protein increased, Carbon dioxide decreased, Cardiac arrest, Chest X-ray abnormal, Cyanosis, Death, Differential white blood cell count abnormal, Dyspnoea, Echocardiogram, Electrocardiogram abnormal, Electrocardiogram QT prolonged, Electrocardiogram T wave peaked, Eosinophil count normal, Fibrin D dimer increased, Full blood count abnormal, Globulin, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Haemoptysis, Leukocytosis, Lung infiltration, Lymphocyte count decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased, Mean cell volume increased, Metabolic acidosis, Monocyte count, Myocardial ischaemia, Neutrophil count increased, Oxygen saturation decreased, PCO2 decreased, Platelet count decreased, Pneumonia, PO2 decreased, Protein total normal, Pulse absent, Respiratory alkalosis, Sepsis, Septic shock, Tachypnoea, White blood cell count, General physical health deterioration, Mean platelet volume, Neutrophil percentage increased, Lymphocyte percentage decreased, Continuous positive airway pressure, Red cell distribution width normal, Mean platelet volume normal, Troponin increased, Troponin T increased, Venipuncture, Eosinophil percentage, Basophil percentage, Monocyte percentage, Base excess negative, Blood electrolytes normal, Procalcitonin increased, Mechanical ventilation, Acute kidney injury, Respiratory symptom, Multiple organ dysfunction syndrome, SARS-CoV-2 test negative, SARS-CoV-2 test, Suspected COVID-19, Agonal respiration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Rivaroxaban 15 and 20 MG, Tylenol, Meclizine 25 MG; Aspirin 18 MG daily, Pravastatin 20 MG daily, Multivitamins, BP formulation, Norvasc 5mg tablet daily . atenolol 25MG tablet daily
Current Illness: none
Preexisting Conditions: Abdominal Aortic Anuerysm, Atypical chest pain, Benign essential Hypertension, Pure hypercholesterolemia
Allergies: none none
Diagnostic Lab Data: Diagnostics: Results for orders placed or performed during the hospital encounter of 02/14/21 CBC WITH DIFFERENTIAL Result Value Ref Range White Blood Cells 10.8 3.8 - 10.8 K/uL Red Blood Cells 3.94 (L) 4.33 - 5.75 M/uL Hemoglobin 13.0 (L) 13.4 - 17.6 g/dL Hematocrit 38.0 (L) 38.2 - 50.2 % MCV 96.4 (H) 82 - 96 fL MCH 33.0 (H) 28.0 - 32.8 pg MCHC 34.2 32.4 - 35.7 g/dL RDW 13.2 11.2 - 15.6 % Platelet Count 131 (L) 140 - 390 K/uL MPV 9.4 6.7 - 10.6 fL Neutrophil % 91.2 % Lymphocyte % 1.7 % Monocyte % 6.8 % Eosinophil % 0.0 % Basophil % 0.3 % Absolute Neutrophils 9.8 (H) 1.8 - 7.1 K/uL Absolute Lymphocytes 0.2 (L) 0.9 - 3.5 K/uL Absolute Monocytes 0.7 0.2 - 0.9 K/uL Absolute Eosinophils 0.0 0.0 - 0.5 K/uL Absolute Basophils 0.0 0.0 - 0.2 K/uL COMPREHENSIVE METABOLIC PANEL Result Value Ref Range Sodium 135 133 - 144 mEq/L Potassium 4.8 3.5 - 5.0 mEq/L Chloride 103 95 - 107 mEq/L Carbon Dioxide 22 22 - 32 mEq/L Anion Gap 10 6 - 15 mEq/L BUN 38 (H) 8 - 24 mg/dL Creatinine 1.41 (H) 0.50 - 1.30 mg/dL Glomerular Filt Rate 44 (L) $g60 mL/min Glucose 164 (H) 70 - 100 mg/dL Albumin 3.4 (L) 3.5 - 5.2 g/dL Calcium 8.5 (L) 8.6 - 10.4 mg/dL AST 39 11 - 41 IU/L ALT 14 11 - 66 IU/L Alkaline Phosphatase 51 35 - 121 IU/L Bilirubin, Total 0.9 <1.5 mg/dL Total Protein 6.6 6.2 - 8.5 g/dL Globulin 3.2 1.8 - 3.7 g/dL A:G Ratio 1.1 (L) 1.2 - 2.7 TROPONIN T, HIGH SENSITIVITY Result Value Ref Range Troponin, High Sensitivity 176 (HH) <12 ng/L PROCALCITONIN Result Value Ref Range Procalcitonin 0.36 (H) <0.25 ng/mL COVID (SARS-COV-2) BY RAPID ANTIGEN Result Value Ref Range COVID-19 Antigen Not detected NOTD TROPONIN T, HIGH SENSITIVITY Result Value Ref Range Troponin, High Sensitivity 233 (HH) <12 ng/L LACTIC ACID Result Value Ref Range Lactate 2.5 (H) 0.4 - 2.0 mmol/L CRP C REACTIVE PROTEIN QUANT Result Value Ref Range C Reactive Protein, Quantitative 7.34 (H) <0.80 mg/dL COVID AG DIRECT OPTICAL BILL Result Value Ref Range CPT 87811 Covid Antigen Direct Bill Billed for services performed D-DIMER Result Value Ref Range D-dimer 0.53 (H) <0.50 ug/mL FEU ARTERIAL BLOOD GAS Result Value Ref Range Patient Oxygen 100% pH, Arterial 7.46 (H) 7.35 - 7.45 pCO2, Arterial 29 (L) 30 - 45 mmHg pO2, Arterial 54 (L) 75 - 95 mmHg Base Deficit 2 0 - 2 Oxygen Saturation, Arterial 87 (L) 95 - 98 % Bicarbonate, Arterial 20 (L) 22 - 26 mmol/L Specimen type Arterial TCO2, Arterial 21 20 - 30 mEq/L Allens Test ALLENS TEST OK EKG (HOSPITAL) Result Value Ref Range Systolic BP 107 mmHg Diastolic BP 56 mmHg Ventricular Rate 82 BPM Atrial Rate 82 BPM QRS Duration 100 ms Q-T Interval 394 ms QTC Calculation(Bezet) 460 ms Calculated R Axis 17 degrees Calculated T Axis 45 degrees Diagnosis Accelerated Junctional rhythm Nonspecific ST and T wave abnormality Prolonged QT interval or tu fusion, consider myocardial disease, electrolyte imbalance, or drug effects Abnormal ECG When compared with ECG of 10-NOV-2020 10:24, Junctional rhythm has replaced Sinus rhythm Vent. rate has increased BY 30 BPM ST now depressed in Anterior leads CULTURE, BLOOD. Specimen: BLOOD Result Value Ref Range Specimen Description BLOOD 10 mL each bottle Drawn from Left Antecubital area. Venipuncture Culture Pending Report Status Pending CULTURE, BLOOD. Specimen: BLOOD Result Value Ref Range Specimen Description BLOOD 10 mL each bottle Venipuncture Drawn from Left Antecubital area. Culture Pending Report Status Pending Medical Decision Making: Patient is an 89-year-old male who presents emergency department for evaluation of shortness of breath and cough. Differential diagnosis includes, but is not limited to, acute coronary syndrome, pneumonia, pulmonary embolism, reaction from recent COVID-19 vaccine, COVID-19 infection, other viral upper respiratory infection, pleural effusion, or CHF. The patient denies any discrete chest pain at this time, though he has had some chest pain with exertion for the past 6 months. He has had shortness of breath along with his cough, increasing my suspicion for possible infectious process. Upon his arrival, the patient is known to be tachypneic, with normal oxygen saturation rates. He is not tachycardic or febrile, therefore does not meet SIRS criteria at this time. Plan at this time to obtain laboratory evaluations, chest x-ray, and EKG. Low threshold to broaden evaluations to include infectious workup. Please reference the remaining ED Course for further assessment, plan, and disposition documentation. ED Course as of Feb 14 1916 Sun Feb 14, 2021 1230 EKG reveals sinus rhythm at a rate of 82 beats per minute. QRS duration 100 milliseconds. QTC slightly prolonged at 460 milliseconds. There is somewhat concerning peaked T-waves in leads V2 and V3 along with with possible ST elevation in lead V1 this does represent a change from the patient''s previous study in November, 2020. EKG (Hospital) 1315 No leukocytosis. Hemoglobin and hematocrit within normal limits for the patient. No thrombocytopenia. Slight elevation in absolute neutrophil count. CBC (Complete Blood Count) With Differential(!) 1330 Elevated at 176. As the patient has been having pain for the past 2 days, I am uncertain if this is catching the increase in his troponin, or the downtrend. He continues to deny chest pain and has reported that his shortness of breath has resolved. TROPONIN T, HIGH SENSITIVITY(!!) 1419 Electrolytes within normal limits. Creatinine elevated at 1.41, though this is not significantly elevated in comparison to study obtained approximately 3 weeks ago at 1.2. Liver function tests within normal limits. No anion gap. Comprehensive Metabolic Panel(!) 1420 By my interpretation, multifocal bilateral infiltrates, most consistent with COVID-19. Also possible right middle lobe infiltrate, concerning for possible superimposed bacterial pneumonia. This is interesting as the patient did just receive his 2nd COVID-19 vaccine. Plan at this time to broaden infectious work up and order for the patient to receive empiric antibiotics. XR Chest 1V Portable 1437 Elevated at 2.5. I will provide the patient with another fluid bolus as his IVC does appear flat upon ultrasound. Lactic Acid(!) 1503 Continues elevated 233. Will consult cardiology. TROPONIN T, HIGH SENSITIVITY(!!) 1506 IMPRESSION: 1. Significant and concerning patchy airspace opacities of the right upper, right lower and left mid lung, concerning for a pneumonic process. Less likely, viral upper is for infection, including Covid 19, could be present. 2. No other etiology seen for symptoms S: 2/14/2021 14:45 CST Electronically Authenticated D: 2/14/2021 14:42 CST XR Chest 1V Portable 1506 I did have a discussion with the patient''s daughter regarding which she believes her father''s code status is. She agrees that he is likely DNR DNI, but does think that he would like to have the cardiac catheterization completed. I will confirm this with the patient. 1617 Patient noted to become hypoxic to 76%. Borderline hypotensive at 91/55. No associated tachycardia. Slightly tachypneic at 26 br/min. Oxygen increased to 15 L/min and RT paged for BiPAP. After a discussion with the patient, he endorses that he understands what DNR/DNI status means, as his wife recently passed away approximately five months ago. He does share that he wishes to be DNR/DNI, which he believes he has paperwork reflecting. I believe at this time that he is of sound mind to make this decision as well, should we not have paperwork available to us reinforce this. He does request that I contact his daughter. 1621 Bedside cardiac ultrasound does not reveal pericardial effusion. IVC appears flat. Will order for the patient receive a 2nd 500 cubic centimeters bolus. RT is present at the bedside Redding to place NIPPV. 1704 D-dimer does age adjust within normal limit. D-DIMER(!) 1705 Patient with acute primary respiratory alkalosis with secondary metabolic acidosis. Continues to be hypoxic on 100% FiO2 with saturation rates at 89%. At this point in time, I favor the patient''s NSTEMI is secondary to demand ischemia given his ongoing hypoxia. However, given his previous reported history of exertional chest discomfort and dyspnea on exertion, I will at least discuss the patient with another Hospital. ARTERIAL BLOOD GAS(!) 1805 Patient did have a significant desaturation event that resulted after he disconnected himself from NIPPV. Upon my arrival into the room, he was noted to be setting 8% with good waveform. He was cyanotic with agonal respirations. He was noted to have a pulse that corresponded with the monitor at a tachycardic rate. He was rapidly placed in a supine position and of bagged with a non-rebreather to increase his oxygen saturation rates. His oxygen saturation rate did increase, but has not completely recovered. We did bag him for several minutes and his oxygen level is now in the low 80s. He is currently on non-rebreather at 15 liters/minute. He is not following commands. His daughter is present and I did advise her of this recent update. I did speak to another Hospital and inform them that the patient would not be transferred at this time. Patient''s blood pressure is noted to be 124/73 mmHg, therefore I will order him some morphine for air hunger. I did brief the patient''s daughter on his current status and we will have her be present in the room with him. 1851 Patient continued to deteriorate, ultimately coughing up bloody secretions. He was suctioned, but continued to be tachypneic and have increased work of breathing. He became bradycardic with heart rates in the 30s. After a discussion with the patient''s daughter, the decision was made to silence alarms. Patient was accompanied by his daughter, ultimately noted to lose pulses and time of death was called at 1830, confirmed by loss of palpable pulses and lose of auscultated pulses. Time was spent discussing the patient with his daughter. We did expedite his PCR COVID swab so as to ultimately know his COVID-19 status. We did offer to contact additionally family members on the behalf of the patient''s family.
CDC 'Split Type':

Write-up: Patient seen and evaluated by PA-C. with myself. We agreed on the clinical findings and implemented our plan together. Please see PA''s note for details. All relevant procedures supervised. Patient arrived to the emergency department due to respiratory symptoms, hypoxic, reported that Wednesday he received his 2nd dose of COVID vaccine. His initial workup was concern for NSTEMI with elevated troponin and peaked T-waves, his chest x-ray concerning for COVID/pneumonia. Patient initially tolerated oxygen by nasal cannula and sepsis protocol was started including IV fluid resuscitation that was done cautiously due to the concern of COVID with respiratory failure. The biotics were given. PA-C readdressed code status with patient who confirmed that his DNR DNI, she so contacted his daughter. Patient had multiorgan failure including acute kidney injury, and pneumonia with respiratory failure +/- respiratory failure. Due to the concern of NSTEMI patient was initially going to be transfer to was hospital and transfer was started. Patient respiratory status started deteriorating and his blood pressure dropped slightly but improved after 500 cubic centimeters of IV fluid and he was also placed on a NIPPV. Around 6:00 p.m. patient has significantly desaturation and he discontinued himself NIPPV. Due to inability to intubate patient, he was ventilated with BVM, patient is slowly improved saturation levels and was opening his eyes, he was placed on a non-rebreather. At this point there is high concern of ARDS and due to inability to intubate or give for the respiratory support His daughter was at bedside and updated of current medical status and poor prognosis. Patient continued deteriorating and at this point he had agonal breathing. His daughter was at bedside and she was made aware of the futile prognosis of patient due to his respiratory failure. Patient rapidly became bradycardic and went into cardiac arrest. No CPR was done due to the DNI DNR status of the patient. Critical Care Procedure Note Authorized and Performed by: MD Total critical care time: Approximately 30 minutes Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient''s response to treatment; frequent reassessment; and, discussions with other providers. This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see MDM section and the rest of the note for further information on patient assessment and treatment. PE: VITAL SIGNS: BP: 126/75 Pulse: (!) 122 Resp: (!) 40 SpO2: (!) 82 % Temp: 98.1 F ?F (36.7 C) ?C) Height: 5'' 8" (172.7 cm) Weight: 152 lb (68.9 kg) General: Alert, nontoxic, in no acute distress. Lungs: Clear to auscultation bilaterally. CLINICAL IMPRESSION: 1. Sepsis with acute hypoxic respiratory failure and septic shock, due to unspecified organism (HCC) 2. Suspected COVID-19 virus infection 3. NSTEMI (non-ST elevated myocardial infarction) (HCC) 4. Multifocal pneumonia 5. ARDS (adult respiratory distress syndrome) (HCC) 6. Acute kidney injury (HCC) Further care and disposition otherwise as outlined by PA. ED on 2/14/2021 Revision & Routing History Detailed Report Note filed date Mon Feb 15, 2021 8:46 AM

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