Age: 88.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Specialist consultation, Stress, Tachypnoea, Thyroxine free normal, Tri-iodothyronine free normal
Clinical narrative: 89 yo F with PMH of HTN, borderline T2DM,  GERD, hypothyroidism (on armour thyroid d/t prev synthetic T4 alone ineffective), and intermittent phentermine use x  the past few years "to help with energy."   She p/w the onset of rhinorrhea,  ShOB, orthopnea, occ palpitations, nausea, and increasing weakness approx 10 days ago.  She developed BLE edema x 2 days ago.  She was found to be in new onset afib w/ RVR in the ED.  She has had increased heartburn with nausea esp. after eating over the past week  with  associated  increased stress from the death of her daughter from biliary cancer  on  1/31/22--her daughter had tested positive for COVID  (as have ot recent family members)  but the pt feels her death was more  related to the advanced cancer.   The pt denies chest pain, dizziness, syncope, HA, hemoptysis, fever, cough,  vomitting, hematemesis, hematochezia or melena.  Denies NSAID or asa use.   She denies a hx of CAD, CHF, atrial fib,  or edema.  She reports a preop stress test years ago  showed no ischemia. HRs were up to 140s on presentation.  She received cardizem 15mg IVP followed by 5mg/h drip, IVP lasix followed by a drip, and a heparin drip was started  in the ED.  Denies ETOH use;  she is a prev smoker      In the ED,  she is afebrile.  She has visible tachypnea with increased WOB with speech, no hypoxia on RA but 2L NC O2 placed for ease of breathing.  HR 110-120 afib while seen --dilt drip increased to 10mg/h  with stable BP.   Pertinent Labs:   CBC unremarkable.  bicarb 20 w/ nl gap, pro BNP 2,358, TSH <0.01;  FT3  and FT4 nl levels.  5G TNT flat x2 (14<-16).   She is COVID positive.    EKG showed afib w/o acute changes. Pertinent Imaging:   CXR: "Pulmonary edema with small to moderate bilateral pleural effusions and associated bibasilar atelectasis."   Though still dyspneic ,  she feels her breathing is improving.  Hospital Medicine has been asked to admit the patient.  DISCHARGE:Patient was admitted to the hospital medicine service and placed in the COVID isolation unit.  For atrial fibrillation with RVR cardiology was consulted.  She had echocardiogram which showed diastolic dysfunction and abnormal mitral and aortic valves.  Cardiology was consulted.  Ultimately she was rate controlled with diltiazem and carvedilol.  She is anticoagulated with Eliquis.  She will follow-up in the cardiology clinic for further monitoring and treatment of her atrial fibrillation and diastolic heart failure.  She also was found to have significant bilateral pleural effusions.  She underwent right and left-sided thoracentesis.  She has significant improvement after her bilateral thoracentesis were performed.  She did require oxygen initially with 2 L and this was believed to be secondary to her effusions and diastolic heart failure and not due to COVID so she did not require COVID treatment.  She overall did very well during hospital stay.  She has follow-up with PCP next week to have a basic metabolic panel checked to monitor her electrolytes and kidney function since she has been discharged on Lasix 40 mg daily and potassium 20 mEq daily.  Again she will follow in the cardiology clinic as well.  She also had dysuria during hospital stay and urinalysis was consistent with UTI and she completed treatment with antibiotics during hospital stay.  Overall she is significantly improved and will be discharged home in stable condition.