Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Chest X-ray abnormal, Coagulation test, Computerised tomogram head abnormal, Computerised tomogram thorax normal, Culture urine positive
Clinical narrative: Discharge Summary Date of Service Jun-01-2022 0615  Date of Admission Admit Date: May-25-2022  Date of Discharge Date of discharge Jun-01-2022  Allergies strawberries - Not Specified  Ambien - Not Specified  Morphine - Not Specified  Levaquin - Not Specified  Chief Complaint Altered mental status  Lab Results Jun-01-2022 0415 Chemistry GLUCOSE  188BUN  25CREAT  1.0MDRD GFR  55NA  139K  4.4CL  103CALCIUM  7.6CO2  31.4OSMO  286.9ANION GP  9.0BUN/CRE  25.0 May-31-2022 0640 Chemistry GLUCOSE  187BUN  29CREAT  1.1MDRD GFR  49NA  139K  4.3CL  103CALCIUM  7.9CO2  30.7OSMO  288.3ANION GP  9.6BUN/CRE  26.4CRP  1.80TROPI-HS  245 May-31-2022 0517 Serology PROCALC  0.05 May-31-2022 0517 Hematology WBC  10.0RBC  4.39HGB  11.2HCT  35.2MCV  80.2MCH  25.5MCHC  31.8RDW  16.4RDWSD  46.6PLT  143MPV  11.8AUTONEU%  70.5AUTOLYM%  11.6AUTOMON%  9.7AUTOEOS%  0.0AUTOBAS%  0.4AUTONEU#  7.0AUTOLYM#  1.2AUTOMON#  1.0AUTOBAS#  0.0AUTOEOS#  0.0SCAN DIF  YNRBC%  0.3NRBC  0.0HGB/HCT  3.1IG#  0.78IG%  7.8 May-30-2022 0530 Chemistry CRP  3.00 May-30-2022 0530 Serology PROCALC  0.14 May-29-2022 1155 Chemistry TROPI-HS  699 May-29-2022 0433 Chemistry CRP  5.20 May-29-2022 0433 Serology PROCALC  0.37 May-28-2022 0405 Chemistry TROPI-HS  2782CRP  8.70 May-28-2022 0405 Serology PROCALC  0.84 May-27-2022 1330 Chemistry TROPI-HS  5443 May-27-2022 0611 Chemistry TROPI-HS  6755CRP  14.30 May-26-2022 0400 Chemistry TROPI-HS  2428CRP  19.00 May-26-2022 0400 Serology PROCALC  1.88 May-25-2022 1900 Chemistry TROPI-HS  4307 May-25-2022 1613 Coagulation D-DIMER  1.84 May-25-2022 1613 Chemistry CRP  6.30 May-25-2022 1610 Serology COVID  PosINFLUA  NegINFLUB  Neg May-25-2022 1420 Microbiology C UR  Escherichia coli May-25-2022 1415 Urinalysis Department SPECGRAV  1.025U-PH  5.5LEUCOCYT  NegativeNITRITES  PositivePROTEIN  TraceGLUCOSE  NegativeKETONES  NegativeUROBILIN  0.2BILRUBIN  NegativeBLOOD  SmallCOLOR  Lt. YellowCLARITY  ClearMICROSCP  YCULTURE  YCULTIND  YWBC  5-10RBC  0-2SQUAM EP  0-2BACTERIA  4+MUCUS  NoneFINE GRA  1-5 May-25-2022 1415 Chemistry AMPHET  NegBARBIT  NegBENZO  NegCOCAINE  NegMETHADON  NegOPIATES  PosPCP  NegTHC  Neg May-25-2022 1317 Microbiology C BLD  No aerobic or anaerobic growth after 5 nights. May-25-2022 1316 Microbiology ADENO VR  NegC BLD  No aerobic or anaerobic growth after 5 nights.METAPNEU  NegPARAINF1  NegPARAINF2  NegPARAINF3  NegPARAINF4  NegRHINO  NegRSV A  NegRSV B  Neg May-25-2022 1316 Hematology WBC  11.9RBC  4.32HGB  11.3HCT  35.1MCV  81.3MCH  26.2MCHC  32.2RDW  16.2RDWSD  48.2PLT  174MPV  9.8AUTONEU%  74.8AUTOLYM%  5.9AUTOMON%  13.9AUTOEOS%  1.5AUTOBAS%  0.5AUTONEU#  8.9AUTOLYM#  0.7AUTOMON#  1.7AUTOBAS#  0.1AUTOEOS#  0.2NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.41IG%  3.4 May-25-2022 1316 Blood Gas PH  7.390PC02  41.1PO2 ART  69.0BICARB  24.3BE  -0.1CO2 CT  22.2O2 SAT  95.8O2 THER  100TYPEABG  Arterial May-25-2022 1316 Chemistry TROPI-HS  3330TSH  1.24ALCOHOL  0FT4  1.44HGBA1C  5.9LACTATE  1.00MEAN GLU  133PROBNP  4361 May-25-2022 1316 Serology PROCALC  0.95 May-25-2022 1313 Chemistry GLUCOSE  131BUN  11CREAT  1.3MDRD GFR  40NA  141K  3.5CL  104CALCIUM  8.1ALK PHOS  61CO2  24.1AST  20ALT  12AST/ALT  1.7TL PROT  6.1ALBUMIN  2.7TBILI  0.6OSMO  282.5ANION GP  16.4BUN/CRE  8.5 Imaging Results Chest x-ray dated 05/25/2022 shows cardiomegaly, small bilateral pleural effusions, hazy bibasilar opacities that may represent pneumonia, mildly prominent pulmonary vascularity for which pulmonary edema cannot be excluded.  CT head and brain dated 05/25/2022 shows no acute intracranial abnormalities, mild changes of chronic small vessel ischemic disease, right maxillary sinusitis mild.  CT chest with contrast dated 05/25/2022 shows no evidence for mediastinal mass or pathologic lymphadenopathy, bibasilar sub segmental active sees are noted, possible right upper lobe ground-glass airspace opacities, granulomatous disease. The evaluation was limited secondary to the patient's body habitus and motion artifacts.  Venous Doppler of the lower extremities dated 05/25/2022 shows stable chronic DVT in the left superficial femoral vein proximal to distal.  Echocardiogram dated 05/26/2022 shows mild left ventricular chamber enlargement with inferior lateral hypokinesis left ventricular ejection fraction 45-50%. Mild my role regurgitation with left atrial enlargement. Mild tricuspid regurgitation. Aortic valve sclerosis. Grade 1 diastolic dysfunction.  Chest x-ray dated 05/27/2022 shows stable cardiomegaly. Mild bibasilar atelectasis. Small right lung pulmonary opacities. No pneumothorax.  Social History tobacco use Former Smoker, 15 yrs, Smoking Cessation Not Applicable Quit smoking 30 years ago  alcohol use No Known Use  drug use No Known Use  marital status Married  occupation Retired from admissions at hospital   general comment Lives at home with husband  Health Concerns Cardiomyopathy due to COVID-19  Acute COVID-19  Paroxysmal atrial fibrillation  Acute on chronic combined systolic and diastolic heart failure  Acute non-ST segment elevation myocardial infarction  Urinary tract infectious disease  Sepsis  Former Smoker, 15 yrs  Father Deceased  Mother Deceased Malignant tumor of breast; Malignant tumor of lung  Brother Alive Primary malignant neoplasm of testis  Vital Signs Jun-01-2022 0530 HR     44 RR 16 BP       162  / 78 O2Sat 99 Jun-01-2022 0356 T 97.5 HR     43 RR 18 BP   138 / 64 O2Sat 98 May-31-2022 2349 T 98.0 PHYSICAL EXAM General: Patient appears acutely and chronically ill, obese, and is in no acute distress.  Cardiovascular: Regular rhythm. Bradycardic heart rate. No murmurs, rubs or gallops. No lower extremity edema. Radial and dorsal pedal pulses +2 bilaterally.  Respiratory: Lungs clear to auscultation bilaterally but ability to fully appreciate lung sounds is limited due to the disposable stethoscope. Respiratory effort is non-labored. She is currently on 2L via nasal cannula.  Gastrointestinal: Abdomen is soft, obese, nontender and nondistended. No rebound or guarding. No ascites.  Psychiatric: Patient responds to questions appropriately and displays a normal affect. She is pleasant and interactive.  Hospital Course Patient is a 71 year old female who presented to the hospital with sepsis due to a urinary tract infection as well as acute hypoxic respiratory failure secondary to COVID-19 requiring more than her baseline 2L supplemental oxygen HS. She was started on remdesivir due to her hypoxia as well as dexamethasone. During her hospitalization she was found to have an acute cardiac event elevating her troponin and causing wall motion abnormalities seen on echocardiogram. Her troponin was 4307. She also experienced an episode of atrial fibrillation with RVR. Cardiology was consulted in the care of the patient. She underwent cardiac catheterization which did not find CAD causing the cardiac strain but rather a likely viral myocarditis. She was titrated to her baseline oxygen at rest with 2-3L PRN while ambulating. She was started on entresto, coreg, and aldactone for her heart failure. An additional complication during the patient's hospitalization that was encountered was that her heart rate was bradycardic with rates in the 30's and 40's. The patient remained asymptomatic during these episodes. This has not completely resolved resulting in the need for a holter monitor outpatient with close cardiology follow up. The patient has continued to improve and has been deemed stable for discharge both clinically and biochemically.  Condition at Discharge Stable  Discharge Medications ACETAMINOPHEN 650 MG ORALLY EVERY 4 HOURS AS NEEDED for FEVER OR MILD PAIN 1-3 ON PS ASPIRIN LOW DOSE 81 MG ORALLY ONCE A DAY carvedilol 6.25 mg tab 6.25 MG ORALLY TWICE DAILY Dexamethasone Oral Tablet 6 MG 6 MG ORALLY ONCE A DAY (ePrescribed by DO on Jun-01-2022 1017) Eliquis Oral Tablet 5 MG 5 MG ORALLY TWICE DAILY Entresto Oral Tablet 24-26 MG 1 TAB ORALLY TWICE DAILY gabapentin 600 mg tab 600 MG ORALLY TWICE DAILY Lasix Oral Tablet 20 MG Continue taking same as home NP Thyroid 30 mg tab 30 MG ORALLY ONCE A DAY Omeprazole Oral Capsule Delayed Release 20 MG 20 MG ORALLY ONCE A DAY Ondansetron Oral Tablet Disintegrating 4 MG Continue taking same as home Paxil 10 mg tab 10 MG ORALLY ONCE A DAY Percocet 7.5-325 mg tab Continue taking same as home rosuvastatin 20 mg tab 20 MG ORALLY ONCE A DAY SPIRONOLACTONE 25 MG ORALLY ONCE A DAY (ePrescribed by DO on Jun-01-2022 1017) Vascepa 1 gram cap 2 GM ORALLY TWICE DAILY WITH MEALS Vitamin B12 Oral Tablet Extended Release 1000 MCG 1000 MCG ORALLY ONCE A DAY Vitamin D3 Maximum Strength Oral Capsule 125 MCG (5000 UT) 125 MCG ORALLY ONCE A DAY Discharge Disposition Discharge to home with home health  Plan Assessment:  -stable sinus bradycardia, likely secondary to cardiac strain -Cardiac strain secondary to likely viral myocarditis -Sepsis secondary to urinary tract infection due to E. coli and COVID-19 ,   Resolved -Acute hypoxemic respiratory secondary to COVID-19, initially requiring 6L NC,  return to baseline, resolved -COVID-19 infection, vaccinated -Urinary tract infection, E. coli, improved -Elevated troponin, 3300 on admission, with ST depression in leads V3-V5 on EKG, improving -Elevated BNP 4360, possibly due to heart strain -Nocturnal hypoxia, unspecified, possible obstructive sleep apnea and/or obesity hypoventilation syndrome, baseline 2L NC at night -Heart failure with preserved ejection fraction, EF 45-50%, grade I diastolic dysfunction per ECHO 5/26/22 -Essential hypertension, unknown control -Diabetes mellitus type 2 with peripheral neuropathy, controlled, A1c 5.9 on admission -Hyperlipidemia, on rosuvastatin -Obesity class III, BMI 62.6 -History of DVT (May 2017), chronic per Doppler 5/25/22 -Chronic anticoagulation on Eliquis -Chronic kidney disease stage 3b, baseline Cr 1.2-1.4 -History of renal cancer, unspecified, status post right nephrectomy -Hypothyroidism, on levothyroxine -GERD, on omeprazole -Overactive bladder, per history -Herniated discs L4-L6 with spinal stimulator in-situ -Major depressive disorder, unknown severity, on Paxil -Anxiety disorder, unspecified, on Paxil  Plan: - Discharge home with home health. - Resume activity as tolerated. PT for home health will be ordered. - Resume cardiac diet. - Patient will be discharged with a holter monitor for 7 days to monitor patient's bradycardia. - She will be continued on entresto and aldactone outpatient. Her coreg dose has been decreased to 3.125 mg BID given her significant bradycardia. - Her levothyroxine has been discontinued but her NP thyroid has been continued. She will require follow up evaluation of her thyroid function as she was hyperthyroid on her previous medication regimen. - She is to hold her metformin at this time until she has a BMP at the beginning of next week to ensure this does not impair her renal function. - Continue supplemental oxygen 2L at night and 2-3L with ambulation as needed. - Follow up with Dr. (PCP) in 5-7 days. - Follow up with Dr. after discharge.  Primary Care Provider DO       DO  Electronically signed by DO on Jun-01-2022 1510 PrintPrevious Next