Age: 63.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Alanine aminotransferase normal, Anion gap, Anticoagulant therapy, Anticoagulation drug level above therapeutic
Clinical narrative: Hospitalized (1.13.22 - 1.20.22); COVID-19 positive (1.13.22); Fully vaccinated -pfizer x2 d/c summary:  Admission Discharged   1/13/2022 - 1/20/2022 (7 days) Hospital  MD   Last attending ? Treatment team COVID   Principal problem   Discharge Summary A-GNP (Nurse Practitioner) ? ? Cardiology Cosigned by: MD at 1/20/2022  7:46 PM BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: DO Admission Date: 1/13/2022 Discharge Date: 01/20/2022 Presenting Problem: COVID    Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 01/16/2022 Unknown ? COVID 01/13/2022 Unknown ? LVAD (left ventricular assist device) present    Discharge Disposition: home health care svc      Active Issues Requiring Follow-up:  Blood pressure, possibly need losartan titrated Follow up BMP given losartan start Follow up INR   Changes in Medications at Discharge: Hydralazine and Imdur transitioned to losartan, discharged on losartan 50 mg PO daily   DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 64 y.o. male with past medical history of chronic systolic heart failure, ICM s/p HM2 VAD implanted 4/28/15, driveline fracture s/p pump exchange 2/25/18, ischemic CVA 2/2018 with hemorrhagic conversion with residual right sided weakness and expressive aphagia, postop VAD exchange course also complicated by prolonged respiratory failure s/p trach, hypertension, Afib, anemia, obesity, and physical conditioning.    Patient presented to ED 1/13 with progressive weakness. He tested positive for COVID and was transferred to other hospital for further treatment. He has received first 2 vaccines, booster scheduled but had not received yet. He lives at home with his wife and has an aid for help, no known COVID exposures, his wife now has COVID. Workup in the ED significant for; +fevers, good O2 sats on RA, no leukocytosis, normal procalcitonin, but labs noted for AKI with Cr of 1.6. CXR with no acute abnormalities.    He was transferred to hospital admitted for COVID care in VAD patient. ID was consulted and treated with remdesivir. Not given decadron given no hypoxia. His weakness and confusion improved with improvement in COVID. He remained stable throughout hospitalization on RA. He did not receive monoclonal antibodies as option inpatient is not thought to be effective against Omicron. He was given gentle IVFs for AKI and Cr normalized. His INR was subtherapeutic on admit and was bridged with heparin gtt. He was given higher doses of coumadin and kept inpatient until INR therapeutic given that he has HM2 and COVID is prothrombotic. On 1/20 his INR was 2.3 and he was stable for discharge. He was instructed to take Coumadin 3 mg q hs except 4 mg on Mondays with INR recheck on Monday 1/24. He was scheduled for virtual follow up visit.  CONSULTS:  ID PT/OT - recommended home with assist/home PT (has 24/7 assist at baseline)  INPATIENT PROCEDURES: Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None BP 107/80  | Pulse 90  | Temp 36.5 °C (Oral)  | Resp 18  | Ht 1.676 m  | Wt 118.7 kg  | SpO2 97%  | BMI 42.24 kg/m²    Physical Exam Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is obese.  HENT:     Head: Normocephalic.     Nose: Nose normal.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard.     Comments: Normal LVAD hum Weekly driveline dressing c/d/i Warm extremities  No LE edema  Pulmonary:     Effort: No tachypnea or respiratory distress.     Breath sounds: No decreased air movement. No decreased breath sounds, wheezing or rales.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline. He is alert and oriented.    Comments: Mild expressive aphasia and slow speech   Psychiatric:        Mood and Affect: Mood and affect normal  H&P:CHIEF COMPLAINT COVID     Assessment/Plan     ASSESSMENT / PLAN   Plan:  - download VAD waveforms 1/14 am by VAD coordinators; few "no external power and low voltage advisories" 1/12 and 1/13  - INR 1.8 on admit, given that he is HM2 and had no external power, will bridge with heparin gtt - IVFs for AKI - consult ID to help with COVID management      COVID+ - testes positive 1/13  - vaccinated x2, booster is scheduled but not yet received - symptoms for 2 days; weakness/fatigue  - stable on RA and CXR with no acute abnormality, but was febrile in ED  - no indication for dexamethasone or remdesivir at this time given he is not hypoxic - consider monoclonal Ab but after discussion with pharmacist regeneron studies show it is not effective against omicron variant  - will consult ID for their assistance in managing   AKI - Cr 1.6 on admit, baseline ~1.2  - suspect poor PO intake 2/2 progressive symptoms with COVID, hydrate with IVFs    ICM s/p HM2 VAD implanted 4/28/15 as DT Hx VAD pump exchange 2/25/18 - 2/2 pump stoppage due to internal driveline fracture  - VAD interrogated; no external power and low voltage advisories 1/12 and 1/13, patient denies any VAD alarms  - INR goal 2-2.5, cont coumadin - ASA 324 mg daily  - cont weekly driveline dressing changes  - hydralazine, toprol xl, and imdur    Chronic systolic and diastolic heart failure - appears euvolemic    Benign essential hypertension - cont home meds; hydralazine, imdur, toprol xl    Afib - anticoagulation mentioned above    ICD present    CKD2   Hx CVA with residual right sided weakness - cont keppra    Anemia - cont iron supplementation    Physical deconditioning s/p CVA    Depression - wellbutrin    Obesity, BMI 43      DVT prophylaxis: Heparin drip I am admitting this patient to Observation because VAD patient needing close monitoring with COVID infection.   VAD interrogation/programming: I performed an in person assessment of the ventricular assist device (VAD), which is in place due to Ischemic Cardiomyopathy.  The VAD was interrogated including a review of the device parameters as well as device function (estimated flow, power consumption, volume status, waveforms, rate drop events, etc).  The patient and the components of the ventricular assist device were inspected.   - The function of the VAD and current settings appear appropriate.   - The driveline and all components of the VAD appear intact and to be functioning normally.   VAD Type: VAD Heartmate II (LDA) VAD flow: 4.1 L/min VAD power: 5.2 watts VAD pulsatility: 5.6  SUBJECTIVE Patient is a 64 y.o. male with past medical history of chronic systolic heart failure, ICM s/p HM2 VAD implanted 4/28/15, driveline fracture s/p pump exchange 2/25/18, ischemic CVA 2/2018 with hemorrhagic conversion with residual right sided weakness and expressive aphagia, postop VAD exchange course also complicated by prolonged respiratory failure s/p trach (no decannulated), hypertension, Afib, anemia, obesity, and physical conditioning.    Patient presented to ED 1/13 with progressive weakness. He tested positive for COVID and was transferred to other hospital for further treatment. He has received first 2 vaccines, booster scheduled but has not received yet. He lives at home with his wife and has an aid for help. States he has became very weak in last few days (~2 days of symptoms), aide has to help him pull up his pants now. He is a bit more confused than his baseline, patient admits to it, and reports his wife and aide have also noticed increased confusion. He however is still A&Ox4. He denies any SOB, chest pain, cough, abdominal pain, N/V. He has no sick exposures that he is aware of.    In the ED he was febrile. He is not hypoxic, stable on RA. No leukocytosis and normal procalcitonin, but labs noted for AKI with Cr of 1.6. CXR with no acute abnormalities.      I have reviewed pertinent past medical, surgical, family and social history, as well as allergies and current medications. See below.    Review of Systems A 10-point review of systems was completed and all other review of systems negative unless stated above in the HPI. OBJECTIVE Pulse 90  | Temp 37.9 °C (Oral)  | Resp 24  | Ht 1.676 m  | Wt 122.8 kg  | SpO2 94%  | BMI 43.70 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard.     Comments: Normal VAD hum Weekly driveline site c/d/i  No LE edema  Warm extremities  Pulmonary:     Breath sounds: No wheezing or rales.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.     Coloration: Skin is pale.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.     Comments: Weaker right upper extremity  Forgetful    Psychiatric:        Behavior: Behavior normal