Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Bradycardia, COVID-19, Chest pain, Chronic obstructive pulmonary disease, Condition aggravated
Clinical narrative: Patient is a 67 yo F with PMH COPD on 5L O2 at baseline HFpEF, CAD, HTN, OSA, HLD who presented to hospital with acute respiratory failure.  She was found to have acute on chronic respiratory failure secondary to COVID-19 infection along with acute exacerbation of COPD.  She received dexamethasone and completed remdesivir.  She was evaluated by respiratory therapy for home oxygen evaluation and qualified for 2 L of oxygen on exertion.  She was counseled to monitor her blood oxygen levels and if they go below 80% to come back to the ER for reevaluation.  She was encouraged to use her BiPAP at night for sleep apnea.  Cardiology was consulted and echo showed normal EF with mild left atrial enlargement and severe pulmonary hypertension.  They recommended reassessing pulmonary gradients 2 or 3 months after patient has recovered from her COVID infection.  They also would consider referral to heart failure team for ongoing management and monitoring of her pulmonary hypertension.  They recommended that patient have a 30-day cardiac monitor and follow-up as an outpatient.  She was also noted to be in A. fib with RVR.  She then became bradycardic and her metoprolol was discontinued and the patient was maintained on Eliquis Cardizem under 20 mg daily, aspirin 81 mg daily, Crestor 20 mg daily, as needed Lasix.  She was also noted to have hyperkalemia of unknown etiology.  Her potassium went as high as 5.7 requiring hyperkalemic protocol.  Nephrology was consulted and patient was placed on a potassium restricted diet.  She was also treated for ESBL positive E. coli UTI.  She was also found to have constipation but was hesitant to maintain a good bowel regimen.  The patient ultimately did have a bowel movement and understands the importance of maintaining a good bowel regimen.  On the day of discharge patient was in good condition and all questions and concerns were addressed.   Hyperkalemia Question etiology 5.4--5.7--5.6--4.3   Appreciate nephrology input--Low K restricted diet   Acute on chronic respiratory failure 2/2 to Covid 19 infection AECOPD OSA Resolved Currently on RA but qualifies for 2LPM on exertion On 2-3 L O2 at home at baseline- can go up to 5 L, On CPAP at home DW patient--she has a pulse oximeter at home--if below 88% needs to come to the ER.  Not to go up to high and goal is 92% or greater.  If symptomatic needs to be seen by PCP or ER     ESBL E Coli UTI Leukocytosis Afeb, VSS Completed antibiotics    COVID 19 infection COVID-positive on 12/17/2022 in the ED.    - Remdesivir trialed and stopped in ICU after rapid symptom resolution, restarted per ID --Dexamethasone 6 mg po for 10 days --IS Atrial fibrillation with RVR Sinus bradycardia Arrythmia Present in the ED, initiated Cardizem with improvement in rates to the low 100s Patient denies history of atrial fibrillation, but per chart review she had an episode of PAF in 2018 No outpatient AC Home meds: Toprol-XL 50 mg daily, diltiazem 120 mg daily Follows with cardiology outpatient, most recently saw Dr. on 11/10/2022 Had an episode of tachycardia and a-fib 12/23 AM, intermittent and baseline 80s.   -Remains rate controlled; Continue home p.o. Cardizem  -Started on Eliquis 12/20 -Risks and benefits of Eliquis discussed and patient agreeable -Metoprolol was decreased from 150-- >50-- >dc d/t bradycardia -cardiology input   HFpEF Pulmonary hypertension Echo on 10/19/2022 with EF 66%, mild mitral stenosis, mild tricuspid regurgitation, and RVSP 85 indicative of pulmonary hypertension Follows with cardiology outpatient as above Home meds include Imdur 30 mg, lisinopril 5 mg, Toprol-XL 50 mg Need to follow up with cardiology regarding pulmonary hypertension   Constipation Maintain good bowel regimen   CAD Elevated troponins Most recent cath in January 2021 with nonobstructive disease, and patent stent in the RCA, medical therapy recommended Initially reported chest pain, denies at this time Troponin 31?27 with negative delta on admission; likely secondary to demand ischemia No concern for acute coronary event at this time EKG with A. fib with RVR, no ST or T wave changes     HTN Continue home meds as above   HLD Continue statin