Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Acute coronary syndrome, Acute myocardial infarction, Acute pulmonary oedema, Acute respiratory failure, Anion gap
Clinical narrative: Hospitalized (4.06.22 - 4.08.22); COVID-19 positive (4.06.22);  fully vaccinated PLUS Booster - Moderna x4 D/C summary:  Discharge Summary PA-C (Physician Assistant-Certified) ? ? Cardiology Cosigned by: MD at 4/9/2022  9:19 AM    Attestation signed by, MD at 4/9/2022  9:19 AM   I have personally interviewed and examined the patient on  4/9/2022 . Management was discussed with PA-C. I agree with the documented findings and plan of care in his/her note.     BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 4/6/2022 Discharge Date: 04/08/2022 Presenting Problem: Flash pulmonary edema      Active Hospital Problems   Diagnosis Date Noted POA ? Flash pulmonary edema   04/06/2022 Unknown Resolved Hospital Problems No resolved problems to display. At discharge, the following medications/referrals/education was given/prescribed:  Beta Blocker was not prescribed due to alternative antihypertensives ACEi / ARB / ARNI were prescribed/continued Spironolactone was prescribed Patient discharged with lasix 40mg daily SGLT2 inhibitor was not prescribed due to multiple new medications starts this admission, will reevaluate outpatient initiation No ICD indicated as diastolic HF or EF > 35% Discharge weight 78.5 kg.   Discharge Disposition: home or self care    Active Issues Requiring Follow-up: - H2O follow-up 4/21/22 - BMP and Mg to assess electrolytes (hypomagnesemia and hypokalemia while inpatient) - Resume janumet (held during admission, following catheterization)  DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patientis a 76 y.o. female with PMH including non-rheumatic AS and MS; HTN, HLD, DM-2, hx tobacco use, iron deficiency anemia.  Patient presented to ED with acute onset dyspnea that woke her up from her sleep at approx 0130. She was transferred to ER for urgent cardiac evaluation of acute hypoxic respiratory failure and HTN urgency with flash pulmonary edema, and abnormal 12-lead EKG.    Hemodynamics improved upon arrival s/p IV lasix and antihypertensives, able to wean off bipap. Troponin trend (13, 113, 210). Limited echo obtained which showed 50% w/hypokinesis of mid-apical anteroseptal/septal walls and apex. Patient underwent coronary angiogram on 4/6 which showed mild-mod nonobstructive CAD, LVEDP 33. She was diuresed with IV lasix with good response. Patient was noted to be hypomagnesemic and hypokalemic during admission, which were replaced aggressively. CT thorax obtained which demonstrates pulmonary infiltrates concerning for pneumonia, negative for PE. Procal elevated at 0.91. Patient became febrile and developed a nonproductive cough during admission. Blood cultures were negative. Patient was treated with rocephin and doxycycline for community acquired pneumonia. Transitioned to cefdinir 300mg BID for 3 days on discharge.    She was continued on losartan and iron supplementation as previously prescribed. New medications at discharge include norvasc 5mg, aldactone 25mg, aspirin 81 daily, lipitor 40mg, lasix 40mg, potassium and magnesium supplementation. Toprol XL and pravastatin were discontinued.    On day of discharge, patient endorses improvement in cough, does not endorse dyspnea. Case was discussed with Dr., we both agree patient is stable for discharge home with close follow-up. Patient expresses agreement with and understanding of treatment plan as outlined above  INPATIENT PROCEDURES: Surgery and Procedures     Past Procedures (4/6/2022 to Today)    Date Time Procedures Providers    04/06/2022 1447 CV LEFT HEART CATHETERIZATION, CORONARY ANGIOGRAM (Primary) BP 162/61  | Pulse 71  | Temp 37.2 °C (Oral)  | Resp 22  | Ht 1.676 m  | Wt 78.5 kg  | SpO2 92%  | BMI 27.93 kg/m²  FIO2 (%): 30 % Physical Exam  H&P: Attestation signed by, MD at 4/6/2022  3:10 PM (Updated)   I have personally interviewed and examined the patient on  4/6/2022 . Management was discussed with PA-C. I agree with the documented findings and plan of care in his/her note.     Brief History:   Patient   is a  76 y.o.    female   patient currently being managed for an acute coronary syndrome.     Diagnostic Data Reviewed:  [N/NML-Normal, b-Borderline, t-Trace, 1-Mild, 2-Moderate, 3-Severe]  CT: No PE; RUL infiltration, pulm nodules  BNP:646  Trop:13>113>210  ECG: NSR LBBB QRS 146  L-TTE 4/22: LV50, m-d AS/SEPT/APEX, RV-N  TTE 6/21: LV72, RV-N, AS-1 (mGr 12), MS-1 (3.4)     Problem List/Assessment:  Acute Coronary Syndrome/NSTEMI  - As evidenced by  flash pulmonary edema  which is likely ischemia-driven (no progressive symptoms of HF prior to this AM such as leg edema, abdominal distention, weight gain, paroxysmal nocturnal dyspnea, orthopnea, or exertional dyspnea despite good physical activity), new left bundle branch block, and escalating troponin level.  - Malignant hypertension adequately controlled with diuresis and labetalol.  - Echocardiogram demonstrated mid to distal anteroseptal/S apical hypokinesis (new from June 2021)  Other(s):  Malignant HTN  (250/110)  COVID  - Positive since Feb 2022, no new symptoms  Diabetes  - Not insulin-dependent, no major complications     Plan(s):  Cardiac catheterization with possible percutaneous intervention (plus LVEDP).  Aspirin 81 mg PO daily.  Ticagrelor pre-intervention.  Heparin 60 units/kg with max of 4000 units IV once followed by pre-procedure Heparin gtt of 12 units/kg.  Atorvastatin 40 mg PO daily at bedtime.  PRN Nitroglycerine and Morphine.   Losartan 25 mg PO daily (concomitant DM).  Metoprolol XL 50 mg PO daily.  Not grossly hypervolemic (no neck vein distention/leg edema), will reassess post LHC.   CHIEF COMPLAINT Flash pulmonary edema   ASSESSMENT / PLAN Assessment:  Acute hypoxic respiratory failure, resolved HTN urgency, resolved Suspected flash pulmonary edema Abnormal 12-lead EKG with new LBBB, troponin elevation, and new WMA on echo raising concern for ACS VHD; mild AS and MS per prior echo  HLD, mixed HTN, benign DM-2 (+)COVID-19 PCR, although initially tested (+) per home test >1 month ago Pulmonary infiltrates on CT (worst in LUL) concerning for PNA, also scattered pulmonary nodules in R upper and middle lobes Hx tobacco use Recommendations/plan: - Presented with acute hypoxic respiratory failure at which time patient appeared to be in flash pulmonary edema in setting of HTN urgency w/concerns for progression of VHD.  - Also with new LBBB on EKG, ascending troponins and echo with WMA raising concern for ACS, although denies any chest pain. - Hemodynamics much improved upon arrival s/p IV lasix and antihypertensives, patient now weaned off bipap and continues to deny any chest pain. - Ordering complete echo to better assess VHD etc. Cont heparin gtt while evaluating for ACS; adding 81mg ASA, high-intensity statin for LDL goal <70 and resume BB/ARB therapy w/uptitration as needed for adequate BP. NPO for possible LHC later today pending ongoing course. - Will also check procal given pulmonary infiltrates on CT concerning for PNA & consider IM input regarding treatments given recent COVID infection.   DVT prophylaxis: Heparin drip   Total time spent with the patient and/or family including floor/unit time was 40 minutes. More than 50% of time was spent in counseling and coordination of care excluding any procedures done SUBJECTIVE Patient is a 76 y.o. female with PMH including non-rheumatic AS and MS; HTN, HLD, DM-2, hx tobacco use, who is being admitted to Cardiology after presenting with acute hypoxic respiratory failure and HTN urgency with suspected flash pulmonary edema, and also being ruled out for ACS 2/2 abnormal 12-lead EKG.   Patient presented to ED early this morning with acute onset dyspnea that woke her up from her sleep at approx 0130. She was hypoxic with pulse ox in low 80s on RA upon arrival and HTN w/SBPs >240. She was initiated on bipap and EKG completed with LBBB and various ST-abn concerning for possible ischemia, but not clear ACS. She was initially paged to INV as possible STEMI, but EKG did not meet STEMI criteria and in interim patient tested (+) for COVID. She was ultimately tx from ER to ER for urgent cardiac evaluation and echo with further recommendations to follow. Prior to transfer patient had received 40 IV lasix, IV labetalol x2, 4000 IV heparin, and was initiated on nitro gtt. Upon arrival she had normalization of BP and remained stable on bipap, which has since been weaned off. She denied any hx chest pain or clear anginal symptoms. Reports actually testing (+) for COVID >1 month ago at home, thus current test not felt to be acute. Repeat EKG with LBBB and non-specific ST-abn, but no evolving ischemic changes. STAT limited echo completed revealing LVEF ~50% w/hypokinesis of mid-apical anteroseptal/septal walls and apex (mild per Dr. & not clearly ACS); also significant MAC raising concern for progression of VHD, although valves not interrogated on study. hsTnT 13--- > 113-- > 210 respectively. Patient initiated on heparin gtt w/plans to undergo CTA thorax to r/o PE, and if negative be admitted to Cardiology for further evaluation/mgmt.    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 BP 143/55  | Pulse 71  | Temp 37.1 °C (Oral)  | Resp 18  | Ht 1.676 m  | Wt 78.5 kg  | SpO2 93%  | BMI 27.93 kg/m²  FIO2 (%): 30 % Physical Exam Vitals reviewed.  Constitutional:      General: She is not in acute distress. HENT:     Head: Normocephalic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Murmur heard.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Comments: Few scattered crackles Abdominal:     Palpations: Abdomen is soft.  Musculoskeletal:        General: No swelling.     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.