Age: 86.0
Sex: F
Vaccine: COVID19
Symptoms: Acute left ventricular failure, Acute respiratory failure, Anticoagulant therapy, Atrial fibrillation, Atrioventricular block first degree
Clinical narrative: COVID+ 1/2/23.  Vaccination Status - Moderna x3 BRIEF OVERVIEW: Admission Date: 1/2/2023 Discharge Date: Jan 5, 2023     DISCHARGE DIAGNOSES 1. New onset/acute systolic CHF 2. Acute hypoxic respiratory failure 3. COVID positive 4. AFib with RVR 5. HTN 6. Depression 7. Neuropathy 8. History of rheumatic fever x2 9. Remote history of precancerous cells in the breast 10. Uterine cancer 11.  CML, in remission HOSPITAL COURSE  1. CHF.  87-year-old patient diagnosed with COVID 10/8/22 as an outpatient.  Did not receive treatment.  Symptoms at the time:  Severe cough and fatigue.  She felt like she got better then got worse again about two weeks before this admission.  She complains of shortness of breath, dyspnea on exertion.  The two nights before admission she noticed some swelling in her ankles and she heard ?whistling? when she laid down.  Cough is nonproductive.  Chest x-ray consistent with heart failure.  Received Zithromax and Rocephin in ER but not continued at the time of admission.  Overnight the first night her respiratory status worsened from requiring 2 L to high-flow nasal cannula.  She was aggressively diuresed and had an excellent diuresis.  After approximately 36 hours she was back to room air.  Fluid balance for the hospitalization -4.1 L (roughly).  Daily weights were not done.  Echocardiogram obtained:  Newly reduced ejection fraction of 42%, LV severely dilated, underlying AFib.  Visually the EF was 35-40%.  With diuresis, her creatinine bumped a little, up to 1.2 (from 1.0).  For this reason I did not start an ARB (Ace inhibitors cause cough).  She was already on a beta-blocker.  She is being discharged on Lasix 20 mg daily.  Her Dyazide is being discontinued.  Recommend follow-up with Cardiology as soon as possible to pursue GDMT as appropriate and possible stress testing.  Suspect that her reduced EF may be due to rapid rates (see below), but she has not had a stress test since 2011 (at least, in our system).   2. AFib with RVR.  Heart rythm on admission was AFib.  She had episodes of RVR.  Historically,  ZIO patch (June 2022):  Runs of VT, SVT, ventricular bigeminy and trigeminy.  Predominant underlying rhythm sinus with first-degree AVB and bundle branch block.  The patient was on Toprol-XL 50 mg daily at home, and this was increased to 50 mg bid.  She tolerated this quite well.  At discharge, her heart rates ranged from 55-100.  She was started on Xarelto 20 mg daily.  Advised of bleeding risk.   3. HTN.  The patient's Toprol-XL was increased to 50 mg bid to control heart rates.  With this increase, Norvasc was discontinued and Dyazide was discontinued.  Blood pressures were well controlled at 109/81 and 129/87 at discharge.     DISCHARGE EXAM 36.4°, 55, 20, 129/87, 99% room air 87-year-old patient A&O x3, NAD Heart:  Irregularly irregular but rate controlled Lungs:  Very faint crackles in the left base Abdomen soft nondistended nontender Extremities no edema   DISCHARGE RECOMMENDATIONS 1. Follow up with PCP 1/12  3:00pm 2. Follow-up within two weeks with Cardiology 3. BMP in one week (this was ordered with results to Dr.) 4. Avoid excess salt in diet 5. Drink to avoid thirst, but do not ?push fluids.?   Patient discharged home in improved and stable condition