Age: 78.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Atrial fibrillation, Bacterial test, Blood pressure abnormal, Brain natriuretic peptide increased, COVID-19
Clinical narrative: TWO hospitalizations (11.20 and 11.26);  COVID-19 positive (11.20.21);  fully vaccinated Admission Date: 11/20/2021 Discharge Date: 11/23/2021 Presenting Problem: Pneumonia due to COVID-19 virus DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Per H&P:  Patient is a 79 y.o. male with PMH s/o HTN, HLD, DM,  2017 inferior stemi s/p PCI to RCA, HFrEF 45-50% who previously followed with Dr. and with ACV cardiology, presented to ED on 11/20 evening due to worsening DOE, orthopnea and shortness of breath.  He went initially to urgent care with CXR returning showing trace pleural effusions and showed patchy airspace opacities in the periphery of both lungs suspicious for developing infectious process. Trace effusions.  ER workup found COVID rapid test neg, CXR showing some peripheral opacities. No leukocytosis. Hgb 10. BNP elevated 4375, initial trop of 36. EKG showing no acute ST changes. He was started on IV lasix. At bedside with daughter patient states he has had worsening orthopnea, DOE, and fatigue x 1 month. Noted his weight up about 5 pounds 245 to 250 lbs. Reports slight decrease in appetite. Denies knowing of any prior diagnosis of atrial fibrillation or heart failure. Patient would like to follow with Dr. who he used to see for cardiology care outpatient after this admission. He endorses cough and nasal congestion over the last week. Family members were positive for covid at start of November but patient was not tested at that time. Full viral swab pending, pcr for covid is negative.  At this time + orthopnea, dyspnea, peripheral edema. Denies chest pain or pressure or anginal sx. No LH or dizziness or sensation of palpitations." #Covid 19 pneumonia. Covid PCR returned positive 11/20/21, but symptoms started 11/6/21 at which time he had myalgias, chills, dyspnea, cough. During his admission, he was afebrile and oxygenating well on room air, so he was deemed low risk for transmitting the virus and infection control advised discontinuing isolation precautions. No Covid specific therapies were indicated as he was not hypoxic.  Admission Date: 11/26/2021 Discharge Date: Nov 28, 2021 PRESENTING PROBLEM: Shortness of breath Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure HOSPITAL COURSE: Patient is a 79 y.o. male  hx of CAD s/p PCI to RCA for inferior STEMI 2017, HTN, HLD, type 2 diabetes, HFrEF LVEF 36%, recent Covid infection (symptoms started 11/6/21) who presented 11/26 with recurrence of orthopnea and shortness of breath. He was admitted 11/20/21 to 11/23/21 for acute on chronic systolic/diastolic heart failure and new onset A fib. He was found to have had progression of LV dysfunction, down to 36% from 45% earlier this summer. He was diuresed from 113kg down to 105kg on discharge at which time he was feeling well with no orthopnea, no peripheral edema, and no shortness of breath with ambulating the hallways. He was transitioned to torsemide 40mg daily with good urine output on day of discharge.  Patient reports he went to his PCP's office for follow up on 11/24, was light-headed so was taken up to the office in a wheelchair. The patient states that the PCP recommended holding torsemide and losartan until he followed up with Dr.  two days later (11/26). Per the office notes, he was found to be borderline hypotensive 90/54 and complaining of light-headedness, so plan was hold losartan. He was at his dry weight of 105kg/231lbs, and no mention was made of holding torsemide in the note.  In the ED, patient was hemodynamically stable, appeared volume overloaded and short of breath so was given IV lasix 40mg with good urine output. UA positive for WBC and bacteria, was given 1g dose of IV ceftriaxone. Pt was transitioned to torsemide 40 mg in the morning and 20 mg in the afternoon. Losartan held on discharge. He was continued on coreg 3.125 mg PO BID. He was discharged with 10-day course of Augmentin for UTI.