Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Pulmonary congestion, Pulmonary fibrosis, Right atrial dilatation, Right ventricular dilatation, Right ventricular failure
Clinical narrative: Date of Admission:  9/22/2023    Date of Discharge:  9/26/2023    Primary Care Physician:  MD   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 8/27/2023 to 9/27/2023.     Issues to be Addressed in Follow-up: Adjust furosemide as needed.    Reason for Hospital Admission (Admitting Diagnosis):  CHF    HPI on admission:  This is a a 92-year-old female with history of chronic respiratory failure on home oxygen, COPD and CHF. 2 weeks ago she was hospitalized for COVID pneumonia in the setting of CHF exacerbation. She was treated with Remdesivir and Dexamethasone. Diuretics were adjusted at discharge. She returns to the ED complaining of increased shortness of breath for the last few days. Denies any fevers or chills. In the ED patient was tachypneic and tachycardic. Increased oxygen requirement compared to her baseline. She uses 2 L of oxygen at home and in the ED she was using 4. Labs unremarkable except for mild troponin elevation. EKG without any evidence of acute ischemia. No leukocytosis. COVID remains positive. Chest x-ray showing mild pulmonary vascular congestion. CT pulmonary angiogram negative for PE. Patient was given breathing treatments and Lasix. Her past medical history is also significant for atrial fibrillation on Warfarin, presence of pacemaker, colon cancer and breast cancer in remission. Frequent hospitalizations.    Hospital Course and Significant Findings:  This is a 92 Y female, significant past medical history of chronic respiratory failure, 2 L home oxygen dependent, COPD, CHF, and recent hospitalization (9/16-  9/17/2023) for COVID infection (treated with remdesivir, dexamethasone), comes in complaining of shortness of breath times several days, new oxygen requirement of 4 L.  In ER worked up, CT PE study was negative, chest x-ray and CT both suggested fluid overload.  Rales noted on exam.  Diagnosed with acute hypervolemia, admitted, started on diuretics.  Doubt covid is a significant contributor to the hypoxia noted this admission.  I&O's have been hit or miss, and weights are unfortunately bed weights of low value.  Have followed FIO2 and exam to grade clinical improvement.    On 9/25/23 Cr bumped up, held furosemide.  Back down to 2 lpm, no rales on exam.      On 9/26/23: Cr improved.  Pt on 2 lpm, no rales, breathing easily.  D/c home, plan to restart Torsemide at 40 mg po qday beginning on 9/27/23.  F/u with PCP later this week.    Studies:  CTPE   1. No central pulmonary embolism (#pe0). 2. Both lungs have areas of diffuse increased density consistent with pulmonary edema or small airways disease. 3. Small-moderate right and trace left pleural effusions have developed since August 2023. 4. Both lungs have mild fibrosis. 5. Heart is enlarged. Coronary artery disease. Probable right heart failure. 6. Stable mediastinal adenopathy which is likely inflammatory. 7. Anasarca.      TTE 4/17/2023 ?  Left Ventricle: Low normal systolic function with an estimated EF of 50 - 55%. Septal motion is consistent with interventricular conduction delay. Septal flattening in systole consistent with right ventricular pressure overload. ?  Right Ventricle: Right ventricle is moderately dilated. Mildly reduced systolic function. ?  Left Atrium: Left atrium is severely dilated. ?  Right Atrium: Right atrium is severely dilated. ?  Mitral Valve: Severe mitral regurgitation. ?  Tricuspid Valve: Moderate tricuspid regurgitation. The PASP is estimated to be 60 mmHg which is severely elevated.   Complications:  none   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) CHF EXACERBATION, UNSPECIFIED   ? EMPHYSEMA   ? ATRIAL FIBRILLATION, PAROXYSMAL     Resolved Hospital Problems   Diagnosis Date Resolved ? COVID-19 PNEUMONIA 09/26/2023   Primary Procedures:   None    Secondary Procedures: None   Consults:  None     Condition on Discharge:  stable   Code Status at Time of Discharge: Full Code   Discharge Disposition:  Home   Discharge Medications: See AVS for discharge meds Pertinent medication changes:   ? Resume torsemide 40 mg po qday                       Hospital Problem List   CHF EXACERBATION, UNSPECIFIED  COVID-19 PNEUMONIA Resolved  ATRIAL FIBRILLATION, PAROXYSMAL  EMPHYSEMA Care Timeline  09/23   Admitted from ED (Observation) 0403 09/26   Discharged 1335  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 9/26/2023)   Discharge Orders BICARBONATE BUN CHLORIDE CREATININE W GFR, CALCULATED GLUCOSE POTASSIUM SODIUM Medication List at Discharge   acetaminophen 500 mg Take 1 to 2 tablets by mouth every 6 hours as needed for pain or fever. Do not exceed 6 tablets in 24 hours  albuterol sulfate 90 mcg/actuation Inhale 2 puffs by mouth every 4 hours as needed for quick relief of asthma symptoms for quick relief of asthma symptoms . 100 days supply for asthma is 1 canister  amiodarone HCl 200 mg Oral DAILY  anastrozole 1 mg Oral DAILY  bisacodyl 10 mg Rectal  AS NEEDED  calcium carbonate 200 mg Oral EVERY 8 HOURS AS NEEDED  carvedilol 3.125 mg Oral 2 TIMES A DAY WITH MEALS  ciclesonide 80 mcg/actuation 1 Puff Inhalation 2 TIMES A DAY, for asthma prevention and control. Rinse mouth well after use  diclofenac sodium 4 g Topical 2 TIMES A DAY AS NEEDED  fluocinolone acetonide 0.01 % Topical 2 TIMES A DAY AS NEEDED  inulin/sorbitol 2 gram Oral  ipratropium/albuterol sulfate 0.5 mg-3 mg(2.5 mg base)/3 mL Use 3 mL via nebulizer 4 times a day the next 2 days then every 4 hours as needed for wheezing or shortness of breath  ketoconazole 2 % Apply to damp skin/hair for 5 minutes and then rinse. Use every 3 to 4 days for up to 8 weeks as directed  levothyroxine sodium 125 mcg Oral DAILY BEFORE BREAKFAST  lidocaine 4 % 1 Patch Transdermal DAILY  loperamide HCl 2 mg Take 2 tablets by mouth after the first loose stool, then 1 tablet after each subsequent loose stool. Do not exceed 4 tablets in 24 hours. Take with 4 to 8 ounces of water  potassium chloride 10 mEq 10 mEq Oral DAILY, with a meal  pravastatin sodium 20 mg Oral DAILY, for cholesterol  torsemide 40 mg Oral DAILY  trazodone HCl 50 mg Oral EVERY BEDTIME  ubiquinol 200 mg 1 capsule Oral  warfarin sodium 2.5 mg Take as instructed by physician or anticoagulation clinic  zinc 50 mg 1 capsule Oral