Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: Pacemaker generated rhythm, Physical deconditioning, Pleural effusion, Polyuria, Right ventricular systolic pressure
Clinical narrative: A 83 y.o. male patient of MD with history of CABG 2006, ICM s/p ICD, atrial fibrillation on coumadin, HTN, HLD, pulm HTN, CKD, dementia presented on 1/17/2023 with ADHD.  Initial workup consistent with COVID as well as CHF exacerbation. Took over as primary post ICU transfer. Patient received aggressive diuresis with lasix gtt and transitioned to oral torsemide. Initiated on midodrine and metoprolol held due to persistent hypotension. Respiratory status improved and currently on 2 L O2. Given the duration of COVID no treatment was indicated. PT/OT recommended SNF, seen by palliative care team CODE STATUS changed to DNR CCA/DNI.  Patient is medically stable to be discharged with outpatient follow up as outlined. Ischemic Cardiomyopathy, Acute on chronic HFrEF, CAD, s/p CABGx3 2006; Symptomatic Hypotension. Has CRT-D in place, AV paced seen on EKG. Recent device interrogation with 99-100% CRT-P. Echo: severely enlarged left ventricle with an EF of 25% and inferior and inferolateral akinesis. He has moderate tricuspid regurgitation and an RVSP of 50. Initiated on lasix gtt (briefly required levophed) with significant diuresis; Transitioned to oral torsemide; Metoprolol DC due to hypotension; Given persistently low symptomatic hypotension initiated on midodrine with improvement. Cortisol normal. No evidence of sepsis. strict I's and O's, daily weight, salt and fluid restriction. Cardiology signed off, outpatient follow up. Acute Hypoxemic Respiratory Failure, Covid 19 Positive, COPD without exacerbation, Acute bronchitis. Persistent acute on chronic left-sided pleural effusion, Hypoxia resolved on RA; Date of COVID positive 1/17/2023, isolation end date 1/27/2022 Chest x-ray with persistent left-sided basilar opacity with moderate to large pleural effusion. ID consulted, recommended supportive measures. Given persistent improvement in hypoxia held off on to thoracentesis for now.  Pleural effusion seems to be chronic likely dependent as well as fluid extravasation with possible trapped lung. If respiratory status gets worse then will recommend left-sided thoracentesis. Given persistent cough with thick sputum and mucus meds, doxycycline, vibratory therapy, incentive spirometer. Improved over all. Patient stable to get out of isolation from 1/28/2023. Paroxysmal Atrial Fibrillation/SSS. Supratherapeutic INR. On warfarin and toprol at home. Admit INR 3.7, currently 2.4, 2.3. HR controlled off metoprolol held due to soft BPs. Resume low dose metoprolol if SBP improves Continue with daily PT/INR Lower back pain-Palpable tenderness midline upper lumbar -Suspect musculoskeletal-Discontinue ibuprofen.  Would avoid NSAID in this age group with increased risk of GI and renal risks in the setting of patient on Coumadin with subtherapeutic INR.-Continue with lidocaine patch -Tylenol - x-ray lumbar spine with DJD -Frequent turns, patient needs to get out of the bed  to the chair.- Improved Elevated Troponin; Likely 2/2 to demand ischemia; Initially a STEMI alert on arrival, evaluated and was deemed not a STEMI rather his abnormal EKG 2/2 to pacemaker; Continue to monitor; Hyperkalemia- resolved; Admit K 5.2, current K 4.1; Monitor with serial RFPs; Stable; Potassium 3.8, keep >4; Hypophosphatemia; Hypomagnesemia Replace; Goals of care; Palliative care discussion noted with patient's wife and daughter. CODE STATUS changed to DNR CCA/DNI. At this point patient wants to attempt rehab and go home subsequently. Discussed with social worker. Severe Physical deconditioning - due to above - PT/OT eval recommending SNF, CM consulted - Pre-cert obtained - Patient medically stable for discharge- Transport arranged for 1/28.