Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Rash erythematous, Rash pruritic, SARS-CoV-2 test negative, Tachycardia, Urinary tract infection
Clinical narrative: The patient is here with complaints of a fever, cough and shortness of breath.  She said is been going on since last Tuesday.  She was tested for Covid and influenza in the clinic which came back negative.  She was instructed this is a viral illness and needs to pass on its own.  She stated that she has been using her inhaler and her daughter's nebulizer without much relief.  She also complains of right lower chest pain.  She denies any swelling in any of her extremities.  Her last fever was this morning.  She stated that the shortness of breath just comes and goes at times.  Patient was treated for UTI last Monday and was on Macrobid.  She noticed over the past couple of days she had had a reddened flat rash on her bilateral lower extremities.  She stated is very itchy  Atrial fibrillation with RVR I48.91   The patient is not ill-appearing or toxic upon arrival to the emergency room.  Her heart rate is tachycardic in the low 100s.  It is sinus rhythm upon arrival.  She did have clear lung sounds.  Patient does have a history of asthma which she feels like is not very controlled at this time.  Patient is moving air well, oxygen levels remain in the mid to upper 90s with room air.  Patient's D-dimer did come back elevated at about 1700.  We did do a CT of the chest to rule out a PE.  There is no acute PEs noted but possible inflammation or metastasis to the bilateral lymph nodes in the hilar area.  We will treat the patient with Augmentin for 10 days to see if we can help decrease the inflammation and have her rescan at that point by her primary care doctor to rule out any suspicious lesions.  While she was in CAT scan and when she came back, the patient was in A. fib with RVR.  She states she never had any issues like this before in the past and her shortness of breath does get worse with the faster heart rate.  Otherwise she is asymptomatic.  The patient was given a bolus of Cardizem and an oral dose of Cardizem with minimal relief of the elevated heart rate.  I did go from the 170s/180s to the 130/140s and still in atrial fibrillation.  I did contact the cardiologist and he recommended avoiding Cardizem due to lack of evidence that it will be beneficial for her in the outpatient setting and starting her on 400 mg of amiodarone twice daily for 2 weeks and then decreasing to 400 mg of amiodarone daily after the initial 2 weeks and to follow-up with him in 2 to 3 weeks for an echo and reevaluation.  The patient will be started on VTE prophylaxis with Eliquis.  The patient stated that she has been on this before and is unsure why.  She said that she was on it when I thought she had Covid because I thought her blood looked thick.  Denies any history of abnormal heart rhythms though.  Her CAT scan results as well as the plan of care were discussed with the patient as well as her primary care provider.  They are agreeable with the plan of care.  Her PCP was comfortable with not further treating her heart rate more than what the cardiologist said due to lack of being symptomatic.  The patient was instructed that she is at risk for stroke due to the atrial fibrillation and that we are trying to prevent that with the blood thinner.  She verbalized understanding is agreeable.  The cardiologist denied any further intervention needed.  We will put her in the hospital for observation on telemetry.  Patient denies any further concerns. The Doctor notified a plan of care and is agreeable.  I do suspect that the patient's rash on her bilateral lower extremities is due to a medication reaction.  We will continue to keep an eye on that.  Chads Vasc 2 score: 1 point, 0.6% stroke risk per year