Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: CHA2DS2-VASc-score, COVID-19, Carbon dioxide decreased, Cardiac pacemaker evaluation, Central venous catheter removal
Clinical narrative: Date of Service Jul-15-2022 0615  Date of Admission Admit Date: Jul-13-2022  Date of Discharge Date of discharge Jul-15-2022  Allergies Penicillin - angioedema  Chief Complaint fast heart rate  Lab Results Jul-15-2022 0425 Hematology WBC  2.2RBC  4.14HGB  12.4HCT  35.7MCV  86.2MCH  30.0MCHC  34.7RDW  13.7RDWSD  43.1PLT  94MPV  12.1AUTONEU%  41.5AUTOLYM%  46.9AUTOMON%  9.4AUTOEOS%  1.8AUTOBAS%  0.4AUTONEU#  0.9AUTOLYM#  1.1AUTOMON#  0.2AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  2.9IG#  0.00IG%  0.0 Jul-15-2022 0425 Chemistry GLUCOSE  93BUN  13CREAT  0.9MDRD GFR  61NA  143K  3.8CL  106CALCIUM  8.5CO2  28.7OSMO  284.8ANION GP  12.1BUN/CRE  14.4TSH  0.63 Jul-14-2022 0427 Hematology WBC  2.2RBC  3.91HGB  11.8HCT  33.7MCV  86.2MCH  30.2MCHC  35.0RDW  13.7RDWSD  42.6PLT  75MPV  11.8AUTONEU%  56.8AUTOLYM%  31.6AUTOMON%  10.2AUTOEOS%  0.9AUTOBAS%  0.5AUTONEU#  1.2AUTOLYM#  0.7AUTOMON#  0.2AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0IG#  0.00IG%  0.0 Jul-14-2022 0427 Chemistry GLUCOSE  100BUN  13CREAT  0.7MDRD GFR  81NA  141K  3.8CL  106CALCIUM  8.4CO2  25.4OSMO  281.5ANION GP  13.4BUN/CRE  18.6TRIG  94CHOL  142LDL CALC  77HDL CHOL  46REL RISK  3.1LDL/HDLD  1.68MAGNESIU  1.8 Jul-13-2022 1735 Urinalysis Department SPECGRAV  1.010U-PH  6.0LEUCOCYT  NegativeNITRITES  NegativePROTEIN  30GLUCOSE  NegativeKETONES  15UROBILIN  0.2BILRUBIN  NegativeBLOOD  Trace-IntactCOLOR  Lt. YellowCLARITY  ClearMICROSCP  YCULTURE  NWBC  0-2RBC  NoneSQUAM EP  0-2BACTERIA  NoneMUCUS  None Jul-13-2022 1615 Chemistry HGBA1C  5.6MEAN GLU  122 Jul-13-2022 1428 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Jul-13-2022 1416 Serology PROCALC  <0.05 Jul-13-2022 1416 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Jul-13-2022 1416 Hematology WBC  3.4RBC  4.72HGB  14.3HCT  40.0MCV  84.7MCH  30.3MCHC  35.8RDW  13.2RDWSD  40.8PLT  79MPV  12.1AUTONEU%  75.6AUTOLYM%  14.1AUTOMON%  10.0AUTOEOS%  0.0AUTOBAS%  0.3AUTONEU#  2.6AUTOLYM#  0.5AUTOMON#  0.3AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  2.8IG#  0.00IG%  0.0 Jul-13-2022 1416 Coagulation PT  12.1INR  1.1PTT  37.9D-DIMER  0.69 Jul-13-2022 1416 Chemistry GLUCOSE  125BUN  10CREAT  0.9MDRD GFR  61NA  135K  3.0CL  99CALCIUM  8.5ALK PHOS  84CO2  21.8AST  22ALT  22AST/ALT  1.0TL PROT  7.3ALBUMIN  3.8TBILI  0.6DBILI  0.1OSMO  270.6ANION GP  17.2BUN/CRE  11.1LDH  211CRP  0.9FERRITIN  325LACTATE  1.50MAGNESIU  1.9TROPI-HS  11.4 Jul-13-2022 1352 Serology COVID  PosINFLUA  NegINFLUB  Neg Imaging Results Chest x-ray shows: no acute cardiopulmonary findings. Right internal jugular catheter tip closely approximates the cavoatrial junction.  Echocardiogram shows: Left ventricular systolic function with an LVEF of greater than 60%. Impaired relaxation, grade 1 diastolic dysfunction. Moderate enlargement of left atrium. Mild mitral regurgitation. Anterior mitral valve leaflet appears mildly thickened. Mild mitral valve prolapse involving the anterior mitral leaflet. Aortic cusps appear mildly calcified. Trileaflet aortic valve. Pacemaker wire noted in the right heart. Normal right ventricular size. Normal right ventricular systolic function. Mild tricuspid regurgitation.  Social History tobacco use Former Smoker, 15 yrs, Smoking Cessation No  marital status Married  Health Concerns H/O: pacemaker in situ  History of reduction of breast  Rapid atrial fibrillation  Former Smoker, 15 yrs  Father Deceased Malignant tumor of lung @ 77  Mother Deceased @ 86  Sister Deceased Malignant tumor of breast @ 47  Sister Alive 74y Diabetes mellitus; Serum cholesterol borderline high  Vital Signs Jul-15-2022 0305 T 98.5 HR 60 RR     23 BP       152  / 71 O2Sat 95 Jul-14-2022 2130 T 98.4 HR 63 RR     25 BP   144 / 85 O2Sat 94 PHYSICAL EXAM Constitutional: Patient appears stated age and is in no acute distress at this time.  Cardiovascular: Regular rate and rhythm without gallop or rub. Murmur appreciated. No edema present in the lower extremities. Radial and dorsal pedal pulses intact 2+ bilaterally.  Respiratory: Lungs clear to auscultation bilaterally, no wheezing, no rhonchi, no rales. No accessory muscle use, no respiratory distress. Patient is currently on room air.  Gastrointestinal: Abdomen soft, non-tender. No rebound or guarding. No distension. No ascites. No organomegaly.  Psychiatric: Patient responds appropriately to questions and displays normal affect. Appears to have good judgment.  Hospital Course Patient is a 77 year old female who presented to the hospital increased weakness and was found on presentation to the emergency department to be in atrial fibrillation with RVR. The patient was started on a Cardizem drip with additional metoprolol for further rate reduction. She has not been taking her home medications prior to admission due to her COVID-19 infection. She remained stable on room air during her hospitalization. Her pacemaker was interrogated as she had previously had it put in for sick sinus syndrome. Interrogation of the pacemaker revealed that the patient had several episodes of atrial fibrillation from the end of June to presentation at the hospital. Patient did not have a previous history of paroxysmal atrial fibrillation. She was able to be titrated off of the Cardizem drip and remained at an adequate heart rate on her home metoprolol. I calculated the patient's CHADS2 Vasc score as well as her HASBLED score and discussed the results with the patient. Based on the results, the patient was started on Eliquis with shared decision making. On day of discharge I removed the patient's central venous line.  The patient was leaned back as far as she could tolerate, was instructed to hold her breath as the line was removed, and had the site covered immediately with an occlusive dressing. Firm pressure was held to the site for 5 minutes and the patient was instructed to remain in a laying position for a total of 30 minutes after the central venous line was removed. The patient tolerated the procedure well without complication.  Condition at Discharge Stable  Discharge Medications amLODIPine Besylate Oral Tablet 2.5 MG 2.5 MG ORALLY ONCE A DAY Atorvastatin Calcium Oral Tablet 40 MG 40 MG ORALLY ONCE A DAY dicyclomine 10 mg capsule 10 MG ORALLY TWICE A DAY AS NEEDED for DIARRHEA Eliquis Oral Tablet 5 MG 5 MG ORALLY TWICE DAILY (ePrescribed on Jul-15-2022 1027) LOPERAMIDE HCl 2 MG ORALLY ONCE A DAY AS NEEDED for DIARRHEA Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 MG 100 MG ORALLY ONCE A DAY pantoprazole 40 mg tablet, delayed release (enteric coated) 80 MG ORALLY ONCE A DAY ramipril 5 mg capsule 5 MG ORALLY ONCE A DAY sertraline 100 mg tablet 100 MG ORALLY ONCE A DAY Discharge Disposition Discharge to home  Plan Assessments: - Paroxysmal atrial fibrillation with rapid ventricular response, resolved - Current in-situ ICD, placement in 2013 - Tachycardia, now resolved - COVID-19 Positive, on admission, stable - Dyspnea: likely secondary to Afib RVR - Nausea without vomiting, improved - GERD secondary to hiatal hernia vs other - Breast cancer: s/p mastectomy in 1986 - Hypokalemia, present on admission - IBS-M - Chronic diarrhea - Essential Hypertension - Elevated glucose without diabetes or prediabetes (a1c on 7/14/22 of 5.6)  Plan: - Patient will be discharged home. - Resume cardiac diet. - Resume activity as tolerated. - Patient has a HASBLED score of 1 point indicating that she is at relatively low risk for major bleeding. Her risk is 3.4%. Her CHA2DS2VASc score is 4 points indicating a stroke risk of 4.8% per year and 6.7% risk of stroke/TIA/systemic embolism. She is at moderate-high risk. We will start her on apixaban at 5 mg BID for stroke prophylaxis given her paroxysmal atrial fibrillation. The patient has not had recent falls or history of major bleeding events. - Recommend evaluation of the patient's blood pressure medication given her lower extremity edema that resolved previously when her amlodipine had been held. - Patient wishes to see Dr. for her cardiology care as it will be easier for her to get to these appointments. - Patient has an appointment scheduled with Dr. at 10 am on 7/20/22.