Age: 59.0
Sex: F
Vaccine: COVID19-2
Symptoms: Anion gap, Aspartate aminotransferase normal, Asthenia, Auscultation, Basophil count decreased
Clinical narrative: Pt reported heart palpitations. Vitals: 220/112; 101,18 EMS Called @1320;  Pt taken to ER  IN ER: Pt was at covid vaccine clinic, 3 min after receiving vaccine, pt reports onset of continuous palpitations. Denies dizziness, SOB, N/V. C/o Right Rib pain for past few days. Hx of HTN.  Patient is a 59 y.o. female who presents for evaluation of palpitations. Patient was at a vaccine clinic this afternoon, she had just received her COVID booster, when she began experience palpitations which has since improved and are now only intermittent. Staff took her blood pressure and found this to be elevated prompting EMS. Patient denies recent fevers/chills, illness/injury. At the time of interview no complaint for headache, change in vision, difficulty speaking, neck pain, chest pain, shortness of breath, back pain, abdominal pain, or new weakness/numbness/tingling to extremities. Pt describes left rib discomfort with palpation for the last few days (triage note not withstanding).  11/15 @14:37 36.6 °C (97.9 °F) 91 12 (!) 219/115 98 %  Result Date: 11/15/2022 Narrative: Examination:XR CHEST 1 VIEW PORTABLE Indication:Hypertension Comparison:None FINDINGS: No infiltrate or effusion. Cardiac size is within normal limits. IMPRESSION: No evidence of pneumonia or edema. Finalized by MD at 11/15/2022 3:28 PM   EKG: EKG interpretation  EKG interpreted by myself -- Obtained at 1429 shows sinus, rate 92, no acute significant ST segment abnormalities,   LABS: Labs Resulted Up to the Time of Admitted to the Floor  CBC WITH DIFFERENTIAL - Abnormal  Result Value Ref Range Status  WBC 7.84 4.50 - 11.00 K/uL Final  RBC 4.57 4.00 - 5.20 M/uL Final  Hemoglobin 10.9 (*) 12.0 - 16.0 g/dL Final  Hematocrit 36.2 36.0 - 46.0 % Final  MCV 79.2 (*) 80.0 - 100.0 fL Final  MCH 23.9 (*) 26.0 - 34.0 pg Final  MCHC 30.1 (*) 31.0 - 37.0 g/dL Final  RDW 14.3 11.5 - 14.5 % Final  NRBC 0.0 0.0 - 0.2 /100 WBC Final  NRBC Absolute 0.00 0.00 - 0.01 K/uL Final  Platelet Count 366 150 - 450 K/uL Final  Mean Platelet Volume 9.7 9.4 - 12.3 fL Final  Neutrophils 67.9 40.0 - 70.0 % Final  Immature Granulocytes 0.3 0.0 - 0.5 % Final  Lymphocytes 26.0 22.0 - 44.0 % Final  Monocytes 5.1 1.0 - 11.0 % Final  Eosinophils 0.6 0.0 - 7.0 % Final  Basophils 0.1 0.0 - 4.0 % Final  Absolute Neutrophils 5.32 1.80 - 7.70 K/uL Final  Absolute Immature Granulocytes 0.02 0.00 - 0.03 K/uL Final  Absolute Lymphocytes 2.04 1.00 - 4.80 K/uL Final  Absolute Monocytes 0.40 0.30 - 0.90 K/uL Final  Absolute Eosinophils 0.05 0.00 - 0.50 K/uL Final  Absolute Basophils 0.01 0.00 - 0.30 K/uL Final  COMPREHENSIVE METABOLIC PANEL, NON-FASTING - Abnormal  Sodium 139 135 - 145 mmol/L Final  Potassium 4.2 3.5 - 5.0 mmol/L Final  Chloride 102 101 - 111 mmol/L Final  CO2 27 22 - 32 mmol/L Final  Anion Gap 10 3 - 12 mmol/L Final  Glucose, nonfasting 172 70 - 199 mg/dL Final  BUN 12 8 - 20 mg/dL Final  Creatinine 0.7 0.4 - 1.0 mg/dL Final  Calcium 9.9 mg/dL Final  Calcium, Adjusted 9.7 8.5 - 10.5 mg/dL Final  Total Protein 8.1 6.0 - 8.5 g/dL Final  Albumin 4.3 3.0 - 5.0 g/dL Final  Albumin/Globulin Ratio 1.1 1.0 - 2.2 Ratio Final  Bilirubin, Total 0.3 0.2 - 1.3 mg/dL Final  Alkaline Phosphatase 96 38 - 126 IU/L Final  AST (SGOT) 13 (*) 15 - 41 IU/L Final  ALT (SGPT) 10 (*) 14 - 54 IU/L Final  GFR, Estimate >60.0 >60 mL/min Final  GFR, Interpretation see below Final  URINALYSIS WITH MICROSCOPIC (CULTURE, IF INDICATED) - Abnormal  Color, Urinalysis Colorless Final  Turbidity, Urinalysis Clear Final  Spec Grav, Urinalysis 1.005 1.001 - 1.035 Final  pH, Urinalysis 6.5 5.0 - 8.0 Final  Protein, Urinalysis Negative Neg Final  Glucose, Urinalysis Normal Normal Final  Ketones, Urinalysis Negative Neg Final  Bilirubin, Urinalysis Negative Neg Final  Occult Blood, Urinalysis Negative Neg Final  Nitrites, Urinalysis Negative Neg Final  Urobilinogen Normal Normal Final  Leukocyte Esterase Negative Neg Final  WBC, Urinalysis 0-5 0 - 5 /HPF Final  RBC, Urinalysis 0-3 0 - 3 /HPF Final  Sq. Epithelial Cells Occasional (*) None-Rare /LPF Final  T4, FREE  T4, Free 1.06 0.60 - 1.20 ng/dL Final  TSH  TSH 2.11 0.45 - 5.33 mIU/L Final  TROPONIN-I, HIGH SENSITIVITY  Troponin-I, High Sens 2.5 0.0 - 11.9 ng/L Final  Pt given clonidine 0.1mg in ER and D/C home w/ RX for same Prior to DISCHARGE, vital signs are Temp: 36.6 °C (97.9 °F) Temp src: Oral Pulse: 81 BP: 121/79 SpO2: 100 % Oxygen Device: None (Room air). Repeat exam prior to discharge shows patient resting comfortably, symptoms improved, normal hemodynamics, feels ready to go home.  11/17 f/u Patient is currently having diarrhea, cough, fever, and body aches. Patient has not tested for Covid. Referal to Cardio.  11/18 f/u Pt reports SE from BP med. Pt reports taht she cant stand, cannot walk, she feels like she'll faint. Feels like her heart is racing at times, and her pulse is in the 90's. Advised patient to go to the ER. Checked with PA  11/18-11/21 ED to Hospital Admission  HOSPITAL COURSE   HPI:  This is a 59-year-old female with past medical history of hyperlipidemia GERD recent diagnosis of hypertension who comes in secondary to generalized weakness and elevated blood pressure.   As per the patient she received COVID booster 3 days ago and since then noticed that her blood pressure was running very high. She came to the ER and was prescribed clonidine which she started taking but still the blood pressure was running high and she felt very weak today and almost passed out so she decided to come in. The patient also noted that she started having a headache. Denies any chest pain no shortness of breath no cough no fever or chills.   As per patient she has history of white coat syndrome, she has a log of her home blood pressure readings which are all within normal limits.   In ER CTA was done.  Hospital Course: Patient had multiple complaints while she was in the hospital. She had complains of dizziness, fluttering in her chest, diarrhea, and weakness in her bilateral lower extremity. Patient reported lot of the symptoms had started after she got her COVID booster. We offered her an MRI to look for any central lesion but patient adamantly refused and told us that she is not able to sit through closed MRI even with antianxiety medication. Her dizziness and chest fluttering did improve. She had gotten some meclizine and reported improvement. I have checked her orthostatic few times and she has been not orthostatic. In addition her EKG and CT had were negative as well for any acute disease. I also had physical therapy see her in consultation this morning. They recommended home PT for now which will be arranged. She had a CTA done in the ER for complains of chest fluttering and elevated blood pressure. My guess is they wanted to rule out aortic dissection. It was negative for dissection however patient was found to have 0.9 mm lung nodule on the right lower lobe, which Radiology recommended no follow-up if she has no other risk factors. In addition she was found to have a 2 x 2 x 2 cm cystic/masslike lesion in the pancreatic head. Patient denied any weight loss over the last 6 months. But I discussed this case with patient and Dr, oncologist who will arrange for outpatient biopsy as soon as this Wednesday. Patient voiced understanding. For her fluttering in her chest ED team, and the hospitalist team before me had spoken to on-call cardiologist who recommended outpatient follow-up. Patient was asked to follow with Dr for a ZIO patch  Patient remained hemodynamically stable and the patient's biochemical profile was acceptable for discharge home to follow up with the patient's PCP and specialist in a few days to a week's time. Discharge plan and medications were reviewed with patient and/or family member who expressed agreement and understanding; all questions were answered to their satisfaction.   PHYSICAL EXAM  BP 141/83 | Pulse 82 | Temp 36.8 °C (98.2 °F) (Oral) | Resp 18 | Ht 154.9 cm (5' 1") | Wt 54.5 kg | SpO2 100% | BMI 22.70 kg/m²    General: Pt in NAD HEENT: PERL, moist oral cavity Lungs: Not using accessory muscles of respiration, clear to auscultation bilaterally Heart: Regular rate and rhythm, no murmurs, gallops, or rubs Abdomen: Soft, non-tender, non-distended, normal active bowel sounds Extremities: No cyanosis or edema Neurological: No focal deficit  PROCEDURES DURING THIS HOSPITALIZATION   CONSULTS  None  IMAGING  XR Chest 1 View Portable  Result Date: 11/19/2022 Narrative: PROCEDURE: XR CHEST 1 VIEW PORTABLE HISTORY: chest discomfort COMPARISON: 11/15/2022 FINDINGS: Normal cardiomediastinal silhouette, lungs and pulmonary vasculature. No effusions or infiltrates are present. IMPRESSION: Normal chest. Finalized by MD at 11/19/2022 7:15 AM   XR Chest 1 View Portable  Result Date: 11/15/2022 Narrative: Examination:XR CHEST 1 VIEW PORTABLE Indication:Hypertension Comparison:None FINDINGS: No infiltrate or effusion. Cardiac size is within normal limits. IMPRESSION: No evidence of pneumonia or edema. Finalized by MD at 11/15/2022 3:28 PM   CT Head or Brain without IV Contrast  Result Date: 11/20/2022 Narrative: Patient: Time Out: 13:29 Exam(s): CT HEAD Without Contrast History: Reason for Exam: Dizziness, non-specific Additional notes: Blood pressure elevated without history of HTN Exam: CT HEAD Without Contrast Technique more: Axial noncontrast CT of the head with coronal, sagittal reformatted images. CTDI is 42.1 mGy and DLP is 733 mGy- cm. Technique more: Up-to-date CT equipment and radiation dose reduction techniques were employed. Comparison: 8/28/2021 Findings: Redemonstration of slightly prominent ventricles relative to the extra-axial CSF spaces. Negative for frank hydrocephalus. Gray-white matter differentiation is seen to be normal. Posterior fossa, cerebellar tonsils are unremarkable. Redemonstration of calcification of the pineal gland and slightly prominent sella turcica with partially empty sella on the right side. Mild calcification of the cavernous carotid. Opacified left and right sphenoid sinus.   Impression: Impression: 1. No acute intracranial finding. 2. Redemonstration of slightly prominent right greater than left lateral ventricle especially frontal horn. Electronically signed by MD on 11-20-22 at 1329  CTA Chest Abdomen and Pelvis with and without IV Contrast  Result Date: 11/18/2022 Narrative: Patient:  Time Out: 20:42 Exam(s): CTA CHEST W/WO Contrast, CTA ABDOMEN + PELVIS W/WO Contrast IV Amt: IV: 125 EXAM: CT Chest Without and With Intravenous Contrast CLINICAL HISTORY: Reason for Exam: Thoracic aortic aneurysm (TAA) suspected Additional notes: Weakness - Generalized Pt with general weakness and feeling like passing out when standing since getting the COVID shot on Tuesday TECHNIQUE: Axial computed tomographic images of the chest without and with intravenous contrast. CTDI is 25.53 mGy and DLP is 668 mGy-cm. Up-to-date CT equipment and radiation dose reduction techniques were employed. CONTRAST: Patient received IV: 125 of IV contrast COMPARISON: CT 12-22-10 FINDINGS: Pulmonary arteries: Unremarkable. No pulmonary embolism or acute cardiopulmonary abnormality. Aorta: No acute findings. No thoracic aortic aneurysm. Other arteries: Punctate calcifications at the left anterior descending artery. Lungs: Right lower lobe pulmonary nodule measuring 0.9 mm in maximum transverse dimension. Pleural space: Unremarkable. No significant effusion. No pneumothorax. Heart: Unremarkable. No cardiomegaly. No significant pericardial effusion. No evidence of RV dysfunction. Bones/joints: Multilevel degenerative changes of the spine. No acute fracture. No dislocation. Soft tissues: Nonspecific calcifications within the breast bilaterally. Lymph nodes: Multiple enlarged lymph nodes at the left axilla. IMPRESSION: 1. No pulmonary embolism. 2. No evidence of thoracic aortic aneurysm or dissection. 3. Multiple enlarged lymph nodes at the left axilla. Correlate with lab values and recommend outpatient mammographic evaluation. 4. Right lower lobe pulmonary nodule measuring 0.9 mm in maximum transverse dimension. Fleischner Society Guidelines for low-risk patients, no follow-up is necessary. For high-risk patients (smoking history or other known risk factors) an optional chest CT at 12 months could be performed. _______________________________________________ EXAM: CT Abdomen and Pelvis With Intravenous Contrast CLINICAL HISTORY: Reason for Exam: Thoracic aortic aneurysm (TAA) suspected Additional notes: Weakness - Generalized Pt with general weakness and feeling like passing out when standing since getting the COVID shot on Tuesday TECHNIQUE: Axial computed tomographic images of the abdomen and pelvis with intravenous contrast. CTDI is 8.78 mGy and DLP is 349.98 mGy-cm. Up-to-date CT equipment and radiation dose reduction techniques were employed. CONTRAST: Patient received IV: 125 of IV contrast COMPARISON: No relevant prior studies available. FINDINGS: VASCULATURE: Aorta: No acute findings. No abdominal aortic aneurysm. No dissection. Celiac trunk and mesenteric arteries: No acute findings. No occlusion or significant stenosis. Renal arteries: No acute findings. No occlusion or significant stenosis. Iliac arteries: No acute findings. No occlusion or significant stenosis. Lung bases: Unremarkable. No mass. No consolidation. ABDOMEN: Liver: Unremarkable. No mass. Gallbladder and bile ducts: Status post cholecystectomy. No ductal dilation. Pancreas: Mixed cystic and solid partially enhancing lesion at the pancreatic head, measuring 2.1 x 2.1 x 2.0 cm suspicious for pancreatic neoplasm. No ductal dilation. Spleen: Unremarkable. No splenomegaly. Adrenals: Unremarkable. No mass. Kidneys and ureters: Unremarkable. No hydronephrosis. No solid mass. Stomach and bowel: Scattered diverticula in the colon. No diverticulitis. No obstruction. PELVIS: Appendix: No findings to suggest acute appendicitis. Bladder: Unremarkable. No mass. Reproductive: Unremarkable as visualized. ABDOMEN and PELVIS: Intraperitoneal space: Unremarkable. No significant fluid collection. No free air. Bones/joints: Multilevel degenerative changes of the spine. No acute fracture. No dislocation. Soft tissues: Unremarkable. Lymph nodes: Unremarkable. No enlarged lymph nodes. IMPRESSION: 1. No evidence of abdominal aortic aneurysm or dissection. 2. Mixed cystic and solid partially enhancing lesion at the pancreatic head, measuring 2.1 x 2.1 x 2.0 cm suspicious for pancreatic neoplasm. Recommend outpatient gastroenterology referral. Electronically signed by MD on 11-18-22 at 2042  USC Echo Complete  Result Date: 11/20/2022 Narrative: Transthoracic Echocardiography Report (TTE) Demographics Patient Name  Gender Female Patient Number  Race  Visit Number Age 59 year(s) Accession Number Date of Study 11/20/2022 Department  Date of Birth  REPORT: Sonographer Interpreting Physician MD Ordering Physician DO Copy To MD Procedure Type of Study TTE procedure:Echo-TTE. Priority: R Room: 3330Bed: P Procedure Date Date: 11/20/2022 Time: 10:25 AM Study Location: Portable Technical Quality: Limited visualization due to poor acoustical window. Indications:Chest pain. Additional Indications:Other (please specify). Patient Status: Routine Height: 60.98 inches Weight: 120.15 pounds BSA: 1.52 m^2 BMI: 22.71 kg/m^2 Rhythm: Within normal limits HR: 90 bpm BP: 128/56 mmHg Conclusions Summary This is a technically good study with the patient in sinus rhythm. Left ventricular wall thickness is at the upper limits of normal with preserved systolic and diastolic function. Visually estimated LVEF 60-65%. No segmental wall motion abnormalities. Morphologically normal valves with no regurgitation nor stenosis. No effusions. Essentially a normal study. No comparison study. Findings Left Ventricle The left ventricle is normal in size and function. The estimated ejection fraction is 60-65%. There are no regional wall motion abnormalities. The E/a ratio is consistent with normal diastolic function. E/e'<15, suggestive of normal left ventricular end diastolic pressure (LVEDP). Right Ventricle The right ventricle is normal in size and function. Left Atrium The left atrium is normal in size and appearance. The interatrial septum is intact with no evidence of atrial septal defect or patent foramen ovale by color flow doppler. Right Atrium The right atrium is normal in size and appearance. Aortic Valve The aortic valve is trileaflet. There is no aortic regurgitation. Mitral Valve The mitral valve is normal in structure and function. There is no mitral regurgitation. Pulmonic Valve The pulmonic valve is normal in structure and function. There is no pulmonic regurgitation. Tricuspid Valve The tricuspid valve is normal in structure and function. There is no tricuspid regurgitation. The right ventricular systolic pressure could not be estimated, due to insufficient tricuspid regurgitation signal. Great Vessels The aortic root dimension is within normal limits. The inferior vena cava appeared normal in size and decreased >50% with respiration (RAP 3mmHg). Pericardial Effusion There is no evidence of a significant pericardial effusion. Pleural Effusion There is no pleural effusion. M-Mode/2D Measurements & Calculations LV Diastolic Dimension: LV Systolic Dimension: LA Dimension: 2.3 cmAO 3.24 cm 2.23 cm Root Dimension: 2.7 cmLA LV FS:31.2 % LV Volume Diastolic: Area: 10.8 cm^2 LV PW Diastolic: 1.14 57.2 ml cm LV Volume Systolic: Septum Diastolic: 0.99 20.8 ml cm LV EDV/LV EDV Index: 57.2 ml/38 m^2LV ESV/LV LA/Aorta: 0.85 ESV Index: 20.8 ml/14 m^2 LA volume/Index: 23.6 ml LV Area Diastolic: 20.7 EF Calculated: 63.6 % /16m^2 cm^2 LV Area Systolic: 11.9 LV Length: 7.57 cm IVC Inspiration: 1 cm cm^2 Doppler Measurements & Calculations MV Peak E-Wave: 0.98 m/s AV Peak Velocity: 1.3 LVOT Peak Velocity: 0.86 MV Peak A-Wave: 0.89 m/s m/s m/s MV E/A Ratio: 1.1 AV Peak Gradient: 6.76 LVOT Peak Gradient: 3 MV Peak Gradient: 3.84 mmHg mmHg mmHg MV Mean Gradient: 1 mmHg MV Mean Velocity: 0.47 m/s PV Peak Velocity: 0.87 MV E' Septal Velocity: m/s 0.06 m/s PV Peak Gradient: 3.02 MV E' Lateral Velocity: mmHg 0.09 m/s Signature ---------------------------------------------------------------------------- Electronically signed by MD on 11/20/2022 11:34 AM ----------------------------------------------------------------------------  ECG 12 Lead - Standard  Result Date: 11/19/2022 Narrative: Hospital Test Date: 2022-11-18 Pat Name: Department: EMERG Patient ID: Room: EMERG-- Gender: F Technician:  DOB: Requested By:  Order Number:  Reading MD: Measurements Intervals Axis Rate: 83 P: 42 PR: 158 QRS: 20 QRSD: 90 T: 0 QT: 339 QTc: 399 Interpretive Statements SINUS RHYTHM SINCE EARLIER TRACING TODAY @ 14:56, NO SIGNIFICANT CHANGE 0000869324_20221118163730.pdf  ECG 12 Lead - Standard  Result Date: 11/19/2022 Narrative: Hospital Test Date: 2022-11-18 Pat Name: Department: EMERG Patient ID:  Room: EMERG-- Gender: F Technician: DOB: Requested By: Order Number: Reading MD: Measurements Intervals Axis Rate: 81 P: 46 PR: 164 QRS: 34 QRSD: 86 T: 8 QT: 332 QTc: 386 Interpretive Statements SINUS RHYTHM SINCE 15 NOV 2022, NO SIGNIFICANT CHANGE 0000869324_20221118145659.pdf  ECG 12 Lead - Standard  Result Date: 11/15/2022 Narrative: Hospital  Test Date: 2022-11-15 Pat Name: Department: 02 Patient ID: Room: EMERG-- Gender: F Technician: DOB: Requested By: Order Number: Reading MD: Measurements Intervals Axis Rate: 92 P: 27 PR: 157 QRS: 48 QRSD: 90 T: 39 QT: 348 QTc: 431 Interpretive Statements SINUS RHYTHM SINCE 28 AUG 2021, NO SIGNIFICANT CHANGE 0000869324_20221115142955.pdf   RECENT LABS   Recent Results (from the past 24 hour(s))  Basic Metabolic Panel, non-fasting  Collection Time: 11/20/22 4:07 PM  Result Value Ref Range  Sodium 140 135 - 145 mmol/L  Potassium 4.3 3.5 - 5.0 mmol/L  Chloride 108 101 - 111 mmol/L  CO2 27 22 - 32 mmol/L  Anion Gap 5 3 - 12 mmol/L  Glucose, nonfasting 136 70 - 199 mg/dL  BUN 14 8 - 20 mg/dL  Creatinine 0.8 0.4 - 1.0 mg/dL  Calcium 8.9 mg/dL  Calcium, Adjusted 9.1 8.5 - 10.5 mg/dL  GFR, Estimate >60.0 >60 mL/min  GFR, Interpretation see below  ECG Rhythm Strip - Order  Collection Time: 11/21/22 12:05 AM  Result Value Ref Range  ECG Interpretation NSR   Results from last 7 days  Lab Units 11/19/22 0443 11/18/22 1450 11/15/22 1447  WBC K/uL 5.99 5.04 7.84  HGB g/dL 10.3* 11.2* 10.9*  HEMATOCRIT % 33.1* 36.6 36.2   Results from last 7 days  Lab Units 11/20/22 1607 11/19/22 0443 11/18/22 1450 11/15/22 1447  SODIUM mmol/L 140 138 140 139  POTASSIUM mmol/L 4.3 3.2* 4.2 4.2  CHLORIDE mmol/L 108 103 105 102  CO2 mmol/L 27 26 27 27  BUN mg/dL 14 24* 10 12  CREATININE mg/dL 0.8 0.8 0.7 0.7  CALCIUM mg/dL 8.9 9.0 9.9 9.9  TOTAL PROTEIN g/dL -- 6.9 8.1 8.1  BILIRUBIN TOTAL mg/dL -- 0.3 0.3 0.3  ALK PHOS IU/L -- 81 89 96  ALT SGPT IU/L -- 12* 12* 10*  AST SGOT IU/L -- 12* 16 13*   0  Lab Value Date/Time  INR 1.0 (L) 08/28/2021 1912   Results from last 7 days  Lab Units 11/19/22 1642 11/18/22 1450  MAGNESIUM mg/dL 2.0 2.0   FOLLOW UP PLAN   PCP: MD F/U with dr, oncologist in 1 week and GI doctor for pancreatic mass biopsy .  Follow up with Dr, heart doctor for a out patient zio patch   Condition on Discharge: Stable  Disposition: Home   Discharge Activity: As tolerated  Discharge Diet: Regular diet   Pt later found to have neuroendocrine tumor of pancreas