Age: 82.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Glycosylated haemoglobin increased, Hypokinesia, Hypothyroidism, Inability to afford medication, Lactic acidosis
Clinical narrative: Patient is an 83-year-old female with a past medical history of type 2 diabetes mellitus who presents with shortness of breath, cough.  Found to have acute hypoxic respiratory failure requiring BiPAP secondary to COVID-19, now on RA.  Date of symptom onset 4/4.  Started on Decadron and remdesivir, but remdesivir held due to elevated LFTs.  Discontinue Decadron 4/14 with her being off oxygen.  Also found to have new heart failure with reduced ejection fraction, EF 20-25% with wall motion abnormalities.  Cardiology consulted, appreciate recommendations.  Left heart catheterization Friday 4/14 with Dr. with LAD stent placed.  Plan to discharge on Eliquis plus aspirin times 30 days plus Brilinta times 12 months, however, due to patient's insurance had to switch Brilinta for Plavix and Eliquis for Coumadin.  Lovenox bridge prescribed.  Fitted for LIFEVEST on DC.  PT/OT recommend home with assist.  Some difficulty getting medications from pharmacy.  Patient was discharged with her dose of Coumadin and Lovenox for 4/16 (would not wait until 4 pm so we could absolutely make sure she had her coumadin + Lovenox prior to DC). Son will pick up meds at 4pm on 4/16 and CM will follow up to make sure there are no issues.   Acute hypoxic respiratory failure-resolved COVID-19 Infection with sepsis-resolved Symptom onset: 4/4, S/p 3 COVID vaccines/boosters CTA chest negative for pulmonary embolism but does show left lower lobe and let to a lesser extent left upper lobe pneumonitis. -Remdesivir held due to worsening LFTs -Dexamethasone 6mg IV or PO daily x 10 days -- > stopped 4/14 without oxygen requirements -DVT prophylaxis:  coumadin with lovenox bridge -prone positioning as able -limit IVF, 1 dose of Lasix 4/11, 4/12, 4/13-- > now on torsemide daily on 4/15   New Heart Failure with Reduced Ejection Fraction New left bundle branch block NSTEMI Elevated troponin-downtrending Echo 4/10 shows LV dilation, EF 20-25% with wall motion abnormalities, apical wall, and global hypokinesis. Cardiac catheterization 4/14 with Dr. with LAD stent placement -planned for Brilinta times 12 months plus aspirin x 1 month in addition to Coumadin, however, unable to afford Brilinta so changed to Plavix -torsemide -Strict I&Os, daily weights, low salt, cardiac diet -Goal BP <130/80 -aspirin, Lipitor, metoprolol, losartan with plans to transition to Entresto -lifevest on DC -repeat echo 30-60 days, possible AICD    -OP cardiology f/u -OP labs 1 week   New onset Atrial Fibrillation Short episode, now in sinus CHADS VASC: 5 Echo as above. TSH normal Patient unable to afford Eliquis -Continue metoprolol, coumadin/lovenox -plan to start Coumadin with Lovenox bridge on discharge.  Coumadin dose is 5 mg nightly and recheck INR in 3 days (Monday 4/17) -telemetry -holter on DC (ordered)   Type 2 diabetes mellitus-hemoglobin A1 c 7.1.  Discontinue insulin as her steroids likely caused her high insulin requirements.   Unable to afford Jardiance.  On discharge resume home metformin.  Will substitute glipizide for Actos due to heart failure Elevated transaminases-suspect related to COVID.  Hold remdesivir. Improving. CMP in 1 week Hypothyroidism-TSH normal on admission, Synthroid Lactic acidosis-resolved Elevated procal Elevated D dimer- CTA chest negative on admission.  Lower leg edema symmetric, not consistent with DVTs, but consider venous ultrasound QTC 526 with left bundle-branch block-EKG this a.m. shows new T-wave inversions in lateral leads V4-6. Dr. aware   PT/OT: Home with assist, home with home therapy