Age: 70.0
Sex: F
Vaccine: COVID19-2
Symptoms: Pulmonary congestion, Respiratory failure, SARS-CoV-2 test positive, Thrombosis, Treatment noncompliance
Clinical narrative: Patient is a 71 y.o. female patient with history of chronic respiratory failure (baseline 3 L/min), asthma, CAD, TIA, PAF, atrial myxoma, aortic stenosis, prior TAVR (5/30), HFrEF, HTN, DM 2, HLD, hypothyroid, CKD, GERD, IBS, breast cancer, anemia, migraines, chronic pain syndrome, depression who  presented to Medical Center with another episode of hemoptysis   Acute on Chronic hypoxic respiratory failure Requires 3-4L NC at baseline, on this at admission Due to chronic HFrEF, obesity hypoventilation syndrome 7/24 AM needed venti mask to maintain sat >90% Increased WOB, wet lung sounds CXR concern for increased congestive findings VBG drawn prior to BiPAP 7.36/57.2/32  Placed on BiPAP, moved to step down 7/24 Found to have COVID 7/25, see below Trial HHFNC as tolerated, try to move to NC Diuresis with lasix 40mg PO daily   Covid-19 Virus Infection Date of onset of symptoms: circa 7/23 vs 7/15 Symptoms present on admission: unclear Date of covid positive test: 7/25 Vaccination status: vaccinated Imaging: see above Oxygen requirements on admission: 4L Current oxygen requirements: HHFNC Medical therapy: remdesivir and steroids Consultants following: pulm Anticipated special isolation end date: 8/1 based on 7/23 symptom onset    Recurrent hemoptysis Started two days PTA, had similar issue on recent hospital admission last month (discharged on 7/9) Pt reports no other respiratory symptoms, no fever/chills CT findings consistent with known CHF, similar to her 7/7 chest CT  Was recently treated for aspiration pneumonitis and acute CHF which were thought to be etiology Held  Eliquis and ASA, Eliquis use contributed to recurrent hemoptysis Pulmonary consulted Resumed ASA Stable   Acute on Chronic HFrEF Stable cardiomegaly, b/l effusions, and vascular congestion on chest CT initially Continued initially home torsemide, metoprolol, spironolactone, hydralazine, Imdur TTE in June EF 40%, TAVR, mod MS ProBNP 18, 000 (similar to prior admission, was 9000 on discharge) Consulted cardiology per patient request Ordered IV lasix x 2 doses 7/20 but changed to Bumex by cardiology Resumed IV diuresis 7/24 for respiratory decompensation, continue for now and monitor UOP, renal function Changed to oral diuretics    Aortic stenosis L shoulder weakness S/P TAVR this year Pt reporting worsening left arm weakness near TAVR site which has been present since discharge Reported told she had a clot in LUE after TAVR, edema has much improved Unable to locate Doppler with DVT - repeat negative for DVT PT/OT ordered Pt initially agreed but later declined imaging and CTs were cancelled per her request Suspect deconditioning and immobilization post TAVR etiology - discussed with therapy who was in agreement and recommended ongoing therapy ASA as above   Chronic A-fib Rate controlled on metoprolol when taking  Cardiology increased to 100 mg - pt not taking 7/22, 7/23 and rate uncontrolled; agreed to take metoprolol 50 7/23 Held Eliquis this admission for hemoptysis - will not restart a/c on discharge per cardiology Not a candidate for left atrial appendage occlusion due to atrial myxoma Amiodarone discontinued by cardiology last admission; continue metoprolol only HR stable   Iron deficiency Anemia  Hgb 8.1 from baseline 9-10 No need for transfusion at this time; goal Hgb>7 Continue iron supplementation Hgb stable 8.5   CKD stage 3 SCr 1.94 on admission, baseline 1.3-2.0 Off entresto due to kidney disease Cr stable around baseline on diuretics   Obesity Hypoventilation syndrome, morbid obesity Obstructive sleep apnea CPAP at night   DM2 noninsulin dependent Home Rx Bydureon (nonformulary) Ordered SSI A1c 5.3% 7/23 in anemia Follow on steroid, may need dose adjustment