Age: 62.0
Sex: F
Vaccine: COVID19
Symptoms: Vascular graft occlusion, Vomiting, Wall motion score index abnormal, White blood cell count normal
Clinical narrative: Hospitalized (1.20.22 - 1.23.22); COVID-19 positive (1.20.22); Fully vaccinated -pfizer x2  Discharge Summary  MD (Resident) ? ? Cosigned by: MD at 1/24/2022  9:55 AM Attestation signed by  MD at 1/24/2022  9:55 AM I have seen and examined patient independently on 1/23/2022. Discussed with Dr.. I agree with the subjective and physical exam findings and assessment and plan.   Patient has been very anxious prior to discharge. She was reassured and outpatient resources were given by social worker. Her home klonopin which was held during this hospitalization is restarted at discharge.  -  MD, Attending Physician,.  BRIEF OVERVIEW: Discharge Provider:  MD Primary Care Provider:  MD Admission Date: 1/20/2022 Discharge Date: 01/23/2022    Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 01/22/2022 Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Atrial fibrillation with rapid ventricular response (HCC) 01/21/2022 01/22/2022  Discharge Disposition:  home or self care    Active Issues Requiring Follow-up: COVID19 infection, anxiety, diastolic heart failure, afib    Medication changes: - Increase Entresto to high dose - 97/103 - Discontinued ToprolXL   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Tachyarrhythmia  COVID-19  Atrial fibrillation with rapid ventricular response (HCC)  HOSPITAL COURSE: Patient is a 63 y.o. female with a history of 63-year-old female past medical history significant for AFib, coronary artery disease status post CABG X 5, HFpEF who presents with acute onset stabbing chest pain that radiated to her neck and occurred at rest.     In the emergency department, patient was in Afib w/ RVR, with wide complex tachycardia with new left bundle branch block. She was given 5 mg of metoprolol, without improvement. She was given Cardizem, after which heart rate normalized, and CP resolved. Repeat EKG with evidence of resolved left bundle branch block.  High sensitivity troponins were mildly elevated, but flat.  CT scan was performed to rule out dissection, showed evidence of COVID lung disease.  Patient had received Pfizer vaccine, 2 doses, and asymptomatic for COVID. Patient was admitted to Internal Medicine for management of her tachyarrhythmia.   Cardiology was consulted, and recommended echocardiogram. Echo (TTE) with evidence of septal wall motion consistent with LBBB, and LVEF 63%, with LVEF 62% on prior report from 8/2021. She had elevated blood pressures during this admission, and her entresto was increased accordingly.    She also complained of chronic diarrhea for about 1 year, with night stooling and rectal insecurity, with RLQ abdominal pain, that improved after BM. She stated her son, whom she lives with, developed chronic diarrhea for the same time frame.    On 01/22, she complained of chest pain.  Serial EKGs were performed and none showed ischemic changes.  Troponins were drawn in did not show significant elevation or rising delta. She met with social work due to anxiety about returning home, to which she was offered information and resources.  On 01/23, she was discharged home in stable condition with scheduled follow up to Cardiology.  She was instructed to isolate.  She expressed understanding of this plan.    CONSULTS / RECOMMENDATION: Consult Orders (From admission, onward)                IP CONSULT TO CARDIOLOGY      Provider:  Cardiology        Cardiology: Medical management and follow up with Cardiology outpatient   INPATIENT PROCEDURES: BP 154/67  | Pulse 67  | Temp 37 °C (Oral)  | Resp 20  | Ht 1.575 m  | Wt 92.5 kg  | SpO2 95%  | BMI 37.30 kg/m²       Wt Readings from Last 3 Encounters: 01/23/22 92.5 kg 01/07/22 92 kg 12/22/21 93 kg   Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is not diaphoretic.  HENT:     Head: Normocephalic.     Mouth/Throat:     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing or rhonchi.  Abdominal:     General: Abdomen is flat. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.     H&P:  ATTESTATION: Patient personally seen and interviewed on 01/21/2022. Case was discussed in detail with the author of this document. I personally reviewed the history of present illness, pertinent medical history, review of systems, and medications. I repeated pertinent portions of the examination and reviewed the relevant imaging and laboratory data. Agree with documentation below with the following additions or corrections:   Myocardial injury Chest pain Chronic diastolic congestive heart failure Persistent atrial fibrillation CKD stage III   Review of Systems   Constitutional: denies fevers, + fatigue Eyes: denies new vision changes Ears, Nose, Mouth, Throat: denies sore throat Cardiovascular: + chest pain, no edema Respiratory: + shortness of breath, cough Gastrointestinal: + nausea, vomiting, diarrhea Genitourinary: denies pain with urination Musculoskeletal: denies joint swelling Integumentary: denies rashes Neurological: denies dizziness, numbness Psychiatric: denies changes in mood  Endocrine: denies easy sweating Hematologic/Lymphatic: denies easy bleeding    63 yo woman presented due to chest pain, sudden onset, associated with a fib/flutter and RVR. Suspect rate dependant LBBB and rate dependant ischemia. Mild troponin elevation, but this is stable. Found to be COVID +, could be that this was induced by myocardial irritability from COVID infection. Still, appreciate cardiology input. Obtain echocardiogram as COVID-19 can cause myocarditis and regional WMA or changes in EF. Reviewed her recent heart cath showing a normal wedge, normal mean PA pressure, normal CO and CI by fick with reduced by thermodilution. She has some occluded grafts and CTOs, but fairly patient other arteries overall and no intervention was needed at that time. She appears to be back in sinus rhythm with resolution of her chest pain this morning. Continue Eliquis. Will need primary care physician follow up for her elevated TSH. Has not had changes in dosing recently.  ASSESSMENT / PLAN: Pt is a 63 yo F with h/o ischemic cardiomyopathy, CAD s/p CABG, afib (eliquis), T2DM, CKD3, and hypothyroidism who presented on 1/21 with chest pain and was found to be in afib with rvr as well as COVID positive.   #Afib with rvr #chest pain - resolved Pt has h/o ischemic cardiomyopathy, CAD, and afib s/p cardioversion (last 8/2021) and presented with mid-chest, stabbing pain radiating to L neck. Trop was initially normal and symptoms resolved after her hr normalized. EKG initially concerning for LBBB, which resolved with improved rate-control. Suspect symptoms are tachyrhythmia-induced, and episode may have been triggered by COVID infection. S/p IV metoprolol 5 and IV Diltiazem 20 x2. - Cardiology c/s  - Continue eliquis - Continue home Dofetilide   #COVID Vaccinated x2, no booster. Currently asymptomatic.  -CTM   #T2DM Last HbA1c 7.2 in 12/2021. On home Metformin, Dapigliflozin, Lantus 28, and lispro. Has chronic diarrhea from Metformin.  Blood glucose currently in low 200s. - Start Lantus 28, very low-dose corrective - Continue home Gabapentin 400 BID for neuropathic pain   #Hypothyroidism TSH elevated to 60 on admission with decreased T4 and T3.  No recent medication changes.  She had previously been stable (last TSH wnl 12/2021) and at goal on this dose of levothyroxine.  Abnormal lab values the secondary to acute illness versus insufficient medication dose.  Currently asymptomatic. - recheck TSH in a.m. - Continue home Levothyroxine 150 for now   #Ischemic cardiomyopathy #HTN Last echo 8/2021 showed LVEF 62% with mild LA dilation and AR.  Prior echo and 02/2021 showed LVEF 35%. - Continue home Bumex, Spironolactone, Entresto   #GERD: Continue home Pantoprazole 40 daily   #MDD:  Prior hospitalizations for suicidal ideation; last in 12/2021.  Continue home Bupropion 300, Buspirone 10 BID, Citalopram 10, PRN Clonazepam   #Insomnia: Continue home Temazepam nightly,    #HLD: Continue Atorvastatin   Diet: General Full Code DVT prophylaxis: On Eliquis Dispo: pending cardiac workup Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 63 y.o. female who presents today with acute onset, stabbing chest pain radiating to her neck, nausea/vomiting, diaphoresis, and palpitation.  She was relaxing in a chair when symptoms acutely presented. She called EMS at that time, and initial EKG was concerning for a wide-complex tachyarrhythmia and new LBBB. Pain was initially treated with morphine, and symptoms ultimately resolved with improvement in her heart rate.   She has experienced nausea and vomiting over the past couple days.  She has chronic diarrhea attributed to her metformin usage; no recent changes. No baseline dyspnea, chest pain.    She was diagnosed with COVID on admission 1/20.  Currently asymptomatic.  She was vaccinated x2 with Pfizer; last dose in 04/2021.   She has a history of AFib status post multiple cardioversion; last in 2021. At that time, the cardioversion was emergent due to blood pressure.  She is on Eliquis for anticoagulation and takes Toprol, although her dose was decreased 09/2021 due to ongoing dizziness.     She has a h/o CAD s/p CABG.  She states the current pain is similar to her prior anginal pain, which also radiated into her left neck.  However, that pain was more of a pressure than the current stabbing pain.   Former smoker. Former marijuana and remote cocaine usage; no IV drug use.   Review of Systems Constitutional:  Negative for chills, fatigue and fever.  Respiratory:  Negative for cough, shortness of breath and sputum production.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Positive for nausea, vomiting and diarrhea. Negative for abdominal pain and constipation.  Neurological:  Positive for headaches. Negative for light-headedness, numbness/tingling and weakness.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Skin:  Negative for rash and wound.  OBJECTIVE: BP 139/59  | Pulse 59  | Temp 36.7 °C (Oral)  | Resp 18  | Ht 1.575 m  | Wt 97.6 kg  | SpO2 95%  | BMI 39.35 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     General: No scleral icterus. Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Normal range of motion and neck supple. No rigidity.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: She is alert.     Motor: No weakness.