Age: 65.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Acute respiratory failure, Anticoagulant therapy, Aortic valve replacement, Atrial fibrillation, COVID-19
Clinical narrative: Hospitalized (11.5.21); COVID-19 vaccine (11.3.21); fully vaccinated  Admission Date: 11/5/2021 Discharge Date: 11/07/2021  DISCHARGE DIAGNOSES 1. Acute hypoxic respiratory failure 2. COVID-19 pneumonia 3. Chronic obstructive pulmonary disease exacerbation 4. Heart failure with reduced ejection fraction 5. Permanent AFib status post AV node ablation and PM placement  6. Status post mechanical AVR and MVR 7. GERD DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 66 y.o. male who presented with 2 days of worsening shortness of breath.  Patient and family had upper respiratory symptoms for several days and he was experiencing fever, headache, loss of appetite, fatigue, productive cough.  He was tested outpatient for COVID-19 and was found to be positive.  While most symptoms resolved, his shortness of breath continued to get worse and so he presented to the emergency department.  He was concerned as he has underlying chronic obstructive pulmonary disease but does not use oxygen at home and his home inhalers were not helping. Upon arrival he was hypoxic and placed on nasal cannula.  Chest x-ray showed findings of chronic obstructive pulmonary disease and interstitial opacities.  He was given steroids and albuterol and admitted for acute hypoxic respiratory failure due to COVID-19 pneumonia.  His breathing improved with steroids and supplemental oxygen and he was quickly requesting to go back home.  Given his clinical improvement in decreased supplemental oxygen needs, he was evaluated by respiratory therapy who recommended 1 L nasal cannula at rest and 2 L nasal cannula with activity.  He was prescribed steroids to complete a 10 day course in the setting of COVID-19 pneumonia and chronic obstructive pulmonary disease exacerbation.   Additionally, shortly after admission initial labs identified supratherapeutic INR greater than 8. Pharmacy was consulted and recommended 1 time dose of vitamin K which was provided and his evening dose of warfarin was held at that time.  His INR was recheck in the morning and had decreased to 4.4.  Given his significant comorbidities and extremely high risk for clot, further discussion with pharmacy was had regarding his next evening's dose of Coumadin.  The decision was made to give 5 mg and the medication was ordered however this dose was not provided.  On day of discharge, his INR was 3.1.  Pharmacy was again consulted for recommendations regarding resumption of Coumadin.  Plan was to have patient take 2.5 mg the night of discharge and then 5 mg the next six nights, with this cycle repeating every 7 days.  He was to follow-up with Coumadin clinic and have INR rechecked morning of 11/08/2021.  He was instructed if his INR was below 2.5 to use his home Lovenox and urgently contact the Coumadin clinic for further instructions.  Patient verbalized understanding of these instructions and these were reviewed by nursing upon his discharge. He was subsequently discharged home in stable and improved condition with supplemental oxygen as well as skilled nursing and OT services