Age: 77.0
Sex: M
Vaccine: COVID19
Symptoms: Fall, Feeling abnormal, Fibrin D dimer increased, Gait disturbance, Glomerular filtration rate normal
Clinical narrative: Hospitalized (1.24.22 - 1.25.22); COVID-19 positive (1.24.22); Fully vaccinated -moderna x2 d/c summary:Discharge Summary  (Physician) ? ? General Medicine  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 1/24/2022 Discharge Date: 01/25/2022    Active Hospital Problems   Diagnosis Date Noted POA ? Syncope and collapse 01/24/2022 Clinically Undetermined ? COVID-19 virus infection 01/24/2022 Yes ? OSA (obstructive sleep apnea) 11/12/2021 Yes ? Essential hypertension 02/11/2021 Yes ? Benign prostatic hyperplasia, presence of lower urinary tract symptoms unspecified, unspecified morphology 07/10/2017 Yes ? Type 2 diabetes mellitus without complication, without long-term current use of insulin  12/21/2016 Yes ? Dyslipidemia   Yes ? Atrial flutter    Yes ? Coronary atherosclerosis of native coronary artery   Yes   Resolved Hospital Problems No resolved problems to display. Active Issues Requiring Follow-up:  Patient has been set up with an ambulatory electrocardiogram monitor and has been advised to follow-up with his primary care provider in the near future.  He has also been advised that he should not be driving or operating any heavy equipment due to his recent syncopal event of uncertain etiology.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Syncope and collapse [R55] Syncope, unspecified syncope type [R55] COVID-19 virus detected [U07.1]   HOSPITAL COURSE: DATE OF ADMISSION: 01/24/2022     BRIEF HISTORY OF PRESENTING ILLNESS: 78-year-old male with a past medical history significant for coronary artery disease as well as history of atrial fibrillation status post cardioversion and subsequent flutter who presents after suffering a syncopal episode while driving.  There was no reported seizure or seizure-like activity, no loss of bowel or bladder function, no biting of his tongue reported.   Patient did not suffer a motor vehicle accident during his syncopal event while driving as his wife was able to grab the wheel and he awoke spontaneously.  On arrival to the emergency department the patient did not have any focal neurological deficits.  Lab evaluation was remarkable for positive COVID-19 test despite previous COVID-19 vaccination.  Patient was admitted to the hospital for further evaluation.   Patient was monitored on telemetry and had no evidence of arrhythmia.  His initial EKG showed a first-degree AV block but no other dysrhythmia was seen.  He did undergo echocardiogram which showed an ejection fraction of 43% which is similar to his previous echo.  He also underwent MRI of the brain which showed no evidence of ischemia or mass.   Patient had been seen by PT and OT and was not thought to require subacute rehab for therapy based on his evaluation by PT/OT.   Etiology behind the patient's syncopal event was uncertain.  In the setting of his history of coronary artery disease and cardiac arrhythmia, it was presumed that he was most likely suffering from some sort of cardiac syncope but with no abnormal echo findings and no significant EKG changes with minimally elevated high sensitivity troponin I values with no significant change upon repeat testing he was not thought to have any significant cardiac pathology that required any further hospitalization.  Patient was set up with an ambulatory electrocardiogram monitor and advised not to drive and was told to follow-up with his primary care provider for further evaluation.   Of note, the patient did have an elevated D-dimer level but this was in the setting of his COVID-19 infection and with lack of clinical symptomatology/findings that would suggest PE, as the patient was not tachycardic and not hypoxic, suspicion for PE was low and the patient did not undergo CT PE study.     CONSULTS / RECOMMENDATION:   Consult Orders (From admission, onward)   None     INPATIENT PROCEDURES:   BP 133/65  | Pulse 70  | Temp 36.5 °C (Oral)  | Resp 18  | Ht 1.778 m  | Wt 106.6 kg  | SpO2 93%  | BMI 33.72 kg/m²    Physical Exam General: No acute distress           HEENT: Atraumatic, normocephalic, anicteric sclera, oral mucsa appears moist Cardiovascular sample:  Regular rate and rhythm, no murmur, distal pulses 2+ in the bilateral upper extremities Respiratory:  Clear to auscultation bilaterally with no wheezes, no use of accessory muscles Abdomen: Nondistended positive active  sounds soft nontender no appreciable organomegaly  Skin:  Normal color and texture no rashes or lesions slight pretibial edema in the bilateral lower extremities Psych:  Appropriate mood and affect Neuro: Alert and oriented to person place and time   H&P:CHIEF COMPLAINT: Syncope and collapse  ASSESSMENT / PLAN: * Syncope and collapse Assessment & Plan Prior occurrence associated with prodrome light headedness with loc < min and no residual ss . No  care sought .  Today with sudden loc while driving , no position  change, no sz like activity . Loc < min . Notes "tipping to the left when walking initially"  Uncertain etiology vasovagal unlikely as was sitting for > prior , ?covid related vs cardiac source , ecg without acute changes .    Obtain echo , lvef in 2010 was 40% , lexi scan in 2012 with nml ef  Obtain orthostatics Telemetry monitoring with noted past hx atrial flutter  sp cardioversion x2  With possible ataxia will obtain mri brain , neurologically intact now  Neuro checks  Pt /ot evaluation      COVID-19 virus infection Assessment & Plan Notes x3 day mild non productive cough  Vac x2 with no booster as yet  D dimer elevated to 1540 , he has no cxr infiltrate and is on room air    Monitor daily  Lovenox daily  He  Has chronic bilateral leg edema and is obese and  Some what sedentary will obtain us le if rise in d dimer or hypoxemic consider cta thorax    OSA (obstructive sleep apnea) Assessment & Plan continue home cpap   Essential hypertension Assessment & Plan Stable  Obtain orthostatics Cpm bb, aci, hctz adjust prn      Benign prostatic hyperplasia, presence of lower urinary tract symptoms unspecified, unspecified morphology Assessment & Plan Continue flomax Monitor for urine retention    Type 2 diabetes mellitus without complication, without long-term current use of insulin Assessment & Plan Elevated on admit , noted am bs ok  A1c  7.2 Hold metformin  Add corrective insulin monitoring    Dyslipidemia Assessment & Plan   Cpm statin   Atrial flutter  Assessment & Plan History of sp cardioversion x2  Cpm bb  Tele monitor   Coronary atherosclerosis of native coronary artery Assessment & Plan No chest pain , sob  Trop indeterminate x2 with pos delta 7 lvef in 2010 40% with lexi scan 2012 with nml ef    Tele monitoring  Trend trop  Obtain bnp  Cpm lopressor , zestril adjust prn orthostatics  Hold hctz prn Subjective Collapse by Default   HISTORY OF PRESENT ILLNESS: Patient is a 78 y.o. male who presents today with "passing out ". pmh cad,mi,atrial flutter sp cardioversion, osa, dm . This am noted as nml morning . Am bs 220 range. Today while driving per wife in car with sudden loc . She grabbed steering wheel and noted he had placed foot on brake so car was brought to a stop. Loc lasting perhaps <1 min . No reported loss of bowel or bladder function . No observed jerking or sz like movements . Was not noted as somnolent or postictal . He notes did not know what was going on though did not feel confused or disoriented . Was able to stand from car noting that felt unsteady requiring to hold on  To the car stating was tipping into the car when walked around it . No reported speech changes , no facial droop , denies numbness or tingling. Wife drove to home . When stood and walked into home felt fuzzy and needed to sit down . States over time progressively felt better and later was able to walk back out to the car though still holding on to furniture for support . No co chest pain , sob, did feel light headed . He notes six weeks ago with event of first feeling light headed then falling into bushes . He does not feel he passed out then . He did not seek care and has not had trouble with this until today . Notes cough onset x3 days ago non productive of sputum . Does not feel sob though states is able to sleep better sitting up . Has baseline chronic edema following vein harvesting for cabg .  Hx cad with mi no hx chf per patient . He tested pos for covid today . No other ss typical for covid noted. No fever , chills, myalgias, loss of taste or smell . Diet has been at baseline . He has received covid vacc x2 not booster as yet . Currently feels at baseline normal self.  Review of Systems Constitutional:  Negative for chills, diaphoresis, fatigue and fever.  HENT: Negative for ear pain, tinnitus, congestion, rhinorrhea, sore throat and trouble swallowing.  Eyes: Negative for pain, redness and visual disturbance.  Respiratory:  Positive for cough. Negative for wheezing, shortness of breath, chest tightness and sputum production.   Cardiovascular:  Positive for leg swelling. Negative for chest pain, palpitations, orthopnea and PND.  Gastrointestinal:  Negative for heartburn, nausea, vomiting, abdominal pain, constipation, diarrhea, rectal bleeding, blood in stool and trouble swallowing.  Genitourinary:  Negative for difficulty urinating, dysuria, frequency, hematuria and flank pain.  Musculoskeletal:  Positive for edema. Negative for neck pain, back pain, joint pain, joint swelling and muscle pain.  Neurological:  Positive for light-headedness and loss of consciousness. Negative for headaches, speech difficulty, seizures, numbness/tingling and weakness.  Endo/Heme/Allergy:  Negative for adenopathy and easy bleeding or bruising.  Psychiatric/Behavioral:  Negative for depression and anxiety.  Skin:  Negative for rash and wound.  OBJECTIVE: BP 137/87  | Pulse 67  | Temp 36.7 °C (Oral)  | Resp 20  | Ht 1.778 m  | Wt 106.6 kg  | SpO2 97%  | BMI 33.72 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed. He is obese.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General: No scleral icterus.    Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.  Chest:     Chest wall: No tenderness.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: Swelling present. No tenderness or deformity.     Cervical back: Normal range of motion and neck supple.     Right lower leg: Edema present.     Left lower leg: Edema present.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.     Sensory: No sensory deficit.     Coordination: Coordination normal.     Deep Tendon Reflexes: Reflexes normal.     Comments: Grips equal bilaterally No facial droop, speech fluent  Motor strength equal x4  Neg pronator drift  Heal to shin intact   Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Judgment: Judgment normal.