Age: 56.0
Sex: M
Vaccine: COVID19
Symptoms: Haptoglobin decreased, Hypotension, International normalised ratio, International normalised ratio increased, Left ventricular hypertrophy
Clinical narrative: Pt is a 56 y.o. male with a history of nonischemic cardiomyopathy and is s/p LVAD  implant on 6/25/2015.  Patient underwent  pump exchange on 04/26/2017 due to pump thrombosis. 6/6/18 he has had issues with NSVT and SVT when off his beta blockers.  Rhythm stabilized after restarting his Toprol but after admission for sigmoid colon abscess, in 11/2018 he had very frequent VT requiring initiation of mexiletine.   Admitted 8/5-8/13/21 due to recurrent elevation of pump power and flows.  LDH mildly elevated on admission with low haptoglobin and INR that was mildly subtherapeutic and was bridged with a heparin gtt.  Aspirin was increased to 325 mg daily, INR goal was kept at 2.5-3, and Plavix was continued. RHC showed that he was dry and diuretics stopped. RHC also showed that despite high speeds up to 11000 he continued to have a pulse pressure of 27 with an arterial waveform consistent with his AV opening fully. His PCWP slightly decreased. His flows did not increase despite signfiicant increase in his RPM and importantly this was not in the setting of increasing blood pressure ( actually his MAP was relativelty unchanged throughout study). Despite the aforementioned, his hemodynamics showed he was well compensated and not in cardiogenic shock. TEE  done showed possibility of low flows in outflow cannula and CT thorax revealed some narrowing in the outflow as well.  Discussion was had with patient and his sister about his options being limited going forward. Patient not a candidate for pump exchange due to redo surgery as well as lung disease etc., decommissioning his pump would be possible but with low EF there would be further risk of decompensation, and medical management which seemed to be the best option.  Palliative care was consulted for goals of care moving forward and the patient chose to continue to pursue aggressive care. Patient discharged without diuretic with weight of 128.7 kg.   Patient with shortness of breath for several days. Tested positive for COVID on 11/3 and was treated with monoclonal antibodies. He now presents as a transfer from Munson with worsening dyspnea, fever and LLQ abdominal pain. CT thorax negative for PE, no acute pulmonary process. CT abd showed diverticulitis. WBC 14, INR 4.4, creat 1.9, lactic wnl. He was hypotensive with BP 70/40 which improved with 2 liters IV fluids. He was given ceftriazone and flagyl and transferred to SHBW. Patient is tachycardic, tachypneic and febrile on admit. BP 90/56. He complains of ongoing LLQ abdominal pain and dyspnea. Denies edema, chest pain, orthopnea, weight gain, LVAD alarms, driveilne site drainage.         Patient Active Problem List Diagnosis ? Cardiomyopathy, nonischemic (HCC) ? Stage 3a chronic kidney disease (HCC) ? LVAD (left ventricular assist device) present (LVAD Clinic) ? Essential hypertension, benign ? History of tobacco abuse, 30 pack years. ? Heart failure, systolic and diastolic, chronic (HCC) ? COPD (chronic obstructive pulmonary disease) (HCC) ? History of marijuana use ? Obesity, Class II, BMI 35-39.9 ? Anticoagulated on Coumadin ? Antiplatelet or antithrombotic long-term use ? Leukocytosis, unspecified type ? History of hypothyroidism ? Iron deficiency anemia, unspecified iron deficiency anemia type ? Left ventricular assist device (LVAD) complication, subsequent encounter ? SVT (supraventricular tachycardia) (HCC) ? Ventral hernia without obstruction or gangrene ? Tachycardia ? Poor dentition ? Multiple pulmonary nodules, first noted 5/2019, resolved. ? Pleural effusion ? Dyspnea on exertion ? Asthma-COPD overlap syndrome (HCC) ? Counseling regarding advance care planning and goals of care ? Multiple comorbid conditions ? Diverticulitis   Past medical, surgical, family and social history reviewed.