Age: 55.0
Sex: F
Vaccine: COVID19-2
Symptoms: Coronary artery disease, Cough, Diuretic therapy, Dyspnoea, Echocardiogram abnormal
Clinical narrative: Patient is a 56 y.o. female with diabetes, CKD, hypertension and diastolic CHF who presented from home on 9/23/2023 with shortness of breath, cough found to have acute hypoxic respiratory failure and COVID and acute CHF.  For the COVID, patient was initially treated with dexamethasone and remdesivir.  Oxygen was weaned off quickly, therefore she did not need to complete the 5-day course remdesivir or 10-day course dexamethasone.  For the CHF, patient was given IV Lasix.  Echocardiogram 9/23/2023 demonstrated EF 45 to 50% with mild global hypokinesis (slightly lower than March 2023 echocardiogram).  Troponin delta was slightly positive during hospitalization.  Cardiology evaluated and assisted with management.  Patient was initially treated with heparin drip for 24 hours, but this was discontinued since patient did not display any cardiac symptoms.  Cardiology recommended medical management with beta-blocker and Lasix as needed.  She can restart her benicar when creat levels have returned to baseline. Patient will need to follow with cardiology as an outpatient to discuss outpatient Lexiscan stress test.         Assessment and Plan   Acute hypoxic respiratory failure -Suspect secondary to COVID infection and acute CHF (more likely) -COVID-positive 9/23 (husband diagnosed 9/22) -RA sat were 50's on arrival.  Patient was initially on heated high flow, but quickly weaned off. -Patient was room air at discharge. -No further treatment as an outpatient needed.   Acute on chronic diastolic and systolic congestive heart failure Elevated troponin CAD Pulmonary hypertension -Elevated troponin with elevated delta. It was secondary to demand ischemia from COVID infection -History of CAD, heart cath in 2009 showed mild diffuse disease in the LAD, eccentric 80% proximal lesion and small first diagonal, mild diffuse disease in circumflex, 40% mid lesion in RCA.  No intervention was performed. -EKG 9/23/2023 without ST changes -Echocardiogram 9/23/2023 demonstrated EF 45 to 50% with mild global hypokinesia -Cardiology evaluated and assisted with management.  Patient was treated with heparin drip x 24 hours.  Cardiology felt that no intervention was needed in the hospital, and they recommended medical management. -Patient will follow with cardiology as an outpatient.  They may consider outpatient stress Lexiscan. -Patient will be discharged with ASA daily, atorvastatin daily, Toprol-XL 25 mg daily, and Lasix as needed. -If recheck creatinine outpatient is at baseline, Benicar can be restarted. AKI on CKD IIIb -CKD with baseline Cr of 1.6-1.8 range secondary to diabetic and hypertensive nephropathy.  -During hospitalization, creatinine increased to max of 2.25 due to overdiuresis -At discharge, creatinine was 2.09 -Patient will follow with PCP outpatient and recheck creatinine level   COVID-19 - Presented with: Shortness of breath - Symptom onset: 9/20/2023 - Positive COVID-19: 9/23/2023 at hospital - CXR on admission showed extensive patchy infiltrates bilaterally - Oxygen status: Requiring no supplemental oxygen - Decadron: Yes.  Stopped as patient is not requiring oxygen - Remdesivir: Yes.  Stopped after day 2 due to elevated creatinine and patient is on room air -Patient will continue with a 10-day isolation.   Diabetes type 2, insulin-dependent with CKD -Home regimen Lantus 15 units nightly, Amaryl, Ozempic and Victoza -Blood sugars are elevated due to Decadron. -Since patient will not continue with steroids, she will continue with her home medications.   Accelerated hypertension -Home meds include amlodipine Maxide, Benicar -Will not restart Maxide secondary CKD. -Benicar was held at discharge since creatinine was elevated.  If recheck creatinine is back to baseline and BP still elevated, can restart home Benicar. -Patient will be discharged with new medications of amlodipine 10 mg daily and Toprol-XL 25 mg daily   Hematuria -Occurred yesterday of unclear etiology, but she was on heparin gtt -Resolved 9/26/2023   Hyperlipidemia -Continue with lipitor Morbid obesity -BMI of 43, diet modifications recommended