Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Cough, Dyspnoea, Echocardiogram, Echocardiogram abnormal, Ejection fraction decreased
Clinical narrative: a 71 y.o. male who presents today with PMH past medical history of atrial fibrillation, coronary artery disease status post CABG, chronic systolic heart failure, urinary obstruction, type 2 diabetes, hypertension, peripheral vascular disease. Per significant other at the bedside she reports that he has more melena alert oriented times 1-2 however has been less responsive and increasingly drowsy and fatigued over the past 5-7 days. Significant other reports that he had an episode of decreased responsiveness today, was able to arouse and did not lose consciousness during this episode.  Patient reports his blood pressure was low and he had a fever at home although she is unable to report the actual temperature.  Patient significant other reports that he does have a sick contact their son who was recently at a religious Camp reportedly had contact with a COVID positive member and then stayed with them following the camp recently.  Patient endorses cough, mild shortness of breath which was progressive.  Patient also reportedly woke up with chest discomfort starting morning of admission that improved after initial fluid resuscitation in the ER.  Symptoms of increased confusion appear to have started 5-7 days ago but unclear exactly when symptom onset is.   Emergency department Patient hypotensive improving with some mild IVF resuscitation. Placed on 3LPM with initial hypoxemia on arrival.  Labs notable for creatinine 1.78, BUN 45, mild transaminitis, initial troponin 178 downtrending to 155 with proBNP 4219, hemoglobin 12.2, urinalysis not suggestive, COVID-19 PCR positive.  Patient was administered Decadron, DuoNeb and approximately 1 L in IV fluid however emergency department reports he may have gotten 1 L in transit.  Acute Hypoxic Respiratory failure COVID-19 pneumonia COPD not previously on O2  -Cont decadron -Wean oxygen as tolerated -OT/PT, CM -Given unclear symptom onset and confusion will hold  on remdesivir -severe respiratory precautions -x-ray imaging as noted with worsening airspace opacity   AKI  -baseline creat 1.0 -monitor off off diuretics, hold aditional IVF -Trend BMP following initial fluid resuscitation   Chest pain, likely demand ischemia from hypotension on admission Chronic compensated systolic heart failure CAD s/p CABG Paroxysmal Afib -cont eliquis -Consult cardio, appreciate reccs -trops as noted, CP resolved in ED w/ BP improvement -Check Echo -continue metoprolol at lower dose, increased dosing as tolerated given hypotension on admission -hold lisinopril   Acute on chronic Toxic Metabolic Encephalopathy Alcohol use disorder Vascular dementia (aaox1-2 at baseline)  -CT head on admission negative for acute change -significant other reports he has a normally alert oriented times 1-2 but has been less responsive over the past few days but appears back to baseline in emergency department on my evaluation -continue monitor mentation however likely related to above   Generalized weakness  Bilateral lower extremity contractures Gait anormalities Lumbar stenosis Peripheral neuropathy Diabetic + likely ETOH   PT OT, Care Management    PVD Continue home medications   HTN Hold home lisinopril, continue metoprolol XL a decreased dosing.    Type 2 Diabetes On Basal bolus insulin.Cont lantus 20U, recently DC'd on 30U and ISS Titrate as needed.   Diabetic diet.    Possible urothelial neoplasm seen on CT Urinary tension -urology as an outpatient -continue 2 times a day straight catheterization with coude   Inguinal hernia containing appendix -consult gen surgery-no need for surgery at this time.    Dispo: To home when medically stable Diet: Diabetic VTE ppx: eliquis Code: FULL