Age: 74.0
Sex: M
Vaccine: COVID19
Symptoms: Anticoagulant therapy, Atelectasis, Blood creatinine normal, Blood potassium normal, Brain natriuretic peptide decreased
Clinical narrative: Hospitalized (12.25.21);  COVID-19 positive (12.25.21); fully vaccinated Admission Date: 12/25/2021 Discharge Date: Dec 28, 2021 DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Shortness of breath [R06.02] Acute on chronic congestive heart failure, unspecified heart failure type (HCC) [I50.9] Pneumonia due to COVID-19 virus [U07.1, J12.82]  HOSPITAL COURSE:  Patient is a 74 yo man  who was admitted to Hospital 12/25/21 with chest heaviness, increasing chronic LE edema, shortness of breath and orthopnea, all progressively worse over 3 weeks. Symptoms were severe enough over the 10 days PTA to affect his quality of life whereby he felt he would be better off dead. He had been vaccinated against Covid x2 with booster due several weeks prior but felt unwell so did not get this.  He has chronic systolic heart failure, ICM EF 25% with ICD. He has a remarkable deranged lipid management concern (hyperlipidemia/dyslipidemia) that had led to CAD w/ 5v CABG 2009, PAD w/ left LE stent, renal artery stenosis w/ bilateral stents 2012, left subclavian artery stenosis and bilateral carotid artery occlusions. Additionally, he carries dx of hypertension, pulmonary hypertension, hx of lung cancer w/ left lower lobectomy 2018, hx of 15 pack year tobacco with COPD not on oxygen (may use tiotropium INH but this was not clarified), and BPH.  ER staff gave him a dose of Lasix with impressive volume out and immediate improvement if not resolution of his chest heaviness and shortness of breath.  An acute exacerbation of chronic systolic heart failure was diagnosed.  His renal function was excellent w/ creatinine 0.7, eGFR >60, with Lasix continued and chronic edema of bilateral lower extremities improved over his brief stay whereby they were smaller than they had been in a long time per his report.  BNP was 22K but CXR was without clear support for either vascular congestion nor Covid PNA, former not an uncommon finding attributed to lymphatic management of excess fluid, despite respiratory symptom and chronic 3rd spacing. BNP decreased to 11K by discharge. Cardiology helped guide his care.  Echo revealed ejection fraction 25%, lower by 10% from prior review.  Valsartan was stopped and Entresto started.  He discharged with a script sent to the  pharmacy at hospital, informed the 1st month would be free. This was done after he questioned if a delay in picking up scripts at his preferred pharmacy, for 2-3 days would be OK.  Advised it was not so for convenience, a 30 day supply of all his meds were sent to the pharmacy including furosemide 20 daily (new) and potassium chloride 20 daily (new, due to a consistent potassium level of 3.5 while here) with emphasis on his picking these up before his wife collected him at the door. In an attempt to avoid his ever being out of med, refills of all 3 meds were e-scribed to his preferred pharmacy.  Coreg was continued without change.  He understood not to continue valsartan, that this was a component of his new Entresto.  Heart failure recommendations and rule of 2s was placed in his chart by his Cardiology team.  Standing weights at admission and discharge were 73.3 (accuracy of a first measure from a bed scale, 78.3, was in question and the first standing wt was likely collected after his first dose Lasix) and 72.3 respectively.  Troponins slightly elevated but flat; 57, 55 so ACS was not considered a diagnosis on presentation, rather, was thought to be a reflection of myocardial injury related to CHF and Covid infection.  Additional symptoms since 12/17/21 included fatigue, mild cough and poor appetite. His wife tested positive for Covid several weeks prior. Our patient tested negative for Covid 12/16/21, likely around the same time his wife tested positive. He was positive on admission 12/25/21 but symptoms were subtle, distinguished from shortness of breath, chest heaviness and orthopnea rapidly relieved with Lasix, helped make the distinction between these concurrent conditions.  Chest x-ray revealed some atelectasis and/or airspace disease at his right lung base.  D-dimer was consistently and significantly elevated, 4K-5K.  Doppler ultrasound lower extremity was negative for VTE. He never required oxygen nor had fever, tachycardia, nor chest pain to suggest PE. CRP was <3 further supporting lack of evidence for robust inflammatory response related to a Covid infection.  Lovenox 40 SQ daily was administered throughout his stay. He had no indication for Decadron or remdesivir given no O2 in use, and he was not a monoclonal antibody candidate given sx onset was >7 days PTA.  Medications at discharge: ASA 81 d Atorvastatin 80 d Coreg 12.5 BID Imdur 60 BID Entresto 24-26 BID (new) Lasix 20 d (new) KCl 20 d (new) Flomax Tiotropium INH (unclear if in use regularly) Cardiology arranged a BMP 1/3/22  A 2 gm sodium restricted diet was instituted but curiously, no a 2 liter fluid restriction. He enjoys potato chips when home but eats only a few at a time. Fluid restriction of 2L daily was advised at discharge.  He was full code  He discharged home 12/28/21 feeling much better that at presentation, in good condition, but he understands his heart is not well and the gravity of such a diagnosis.