Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Atrial fibrillation, Blood creatinine normal, Brain natriuretic peptide increased, C-reactive protein increased, COVID-19
Clinical narrative: DISCHARGE DIAGNOSES/HOSPITAL COURSE: This 76 y.o. male was admitted on 2/17/2022 to the Hospital.  The following is from the admission history and physical: "CHIEF COMPLAINT: Chest pain HPI: The patient is a 76 y.o.  male  with a history of diabetes, hypertension, and atrial fibrillation, on Eliquis, who presents to the emergency department with for evaluation of chest pain.  Per chart review patient had an Right endarterectomy on 2/7 and he was subsequently discharged home on 2/8.  Per chart review patient had dizziness and tremors as well as shortness of breath with chest discomfort that started after the procedure.   The patient was seen on 2/11 in the emergency department for and tremors dizziness post-endarterectomy.  Patient has a chest x-ray that showed vascular congestion he was treated with dose of IV Lasix and was oral Lasix.  Patient was subsequently discharged home.  Patient states that for the past 3 days he has had dyspnea when he is gone the stairs he states that he has some mid chest pain few days ago but now it is more along his right arm he denies any radiation of the pain patient has a mild dry cough.  Patient states he has some diarrhea that has resolved with his last bowel movement day and a half ago   Patient denies close contact with laboratory confirmed COVID-19.   The patient denies   dysuria,  fevers, chills, nausea, emesis, dizziness, and headaches.   In the emergency department BNP was 684.  His EKG showed A. fib with RVR.   He was treated as listed below"       Acute systolic heart failure.  New diagnosis.  Echo shows significant decrease in ejection fraction of to 35 to 40%.  I reviewed the results of the echo results with the patient and also informed of the mildly dilated aortic aneurysm which I recommended that he continue outpatient follow-up with his primary cardiologist.  The patient does not appear to be severely volume overloaded.  Will attempt some of gentle diuresis with Lasix 40 mg IV every 8 hours x2 doses.  Request cardiology to see the patient tomorrow and determine if further diuresis is indicated.  Will hold amlodipine since this may be worsening his heart failure and and start the patient on metoprolol XL 25 mg daily with holding parameters continue digoxin PTA 2/18 patient was seen by cardiology and the following is from his note: " ASSESSMENT: 1.  HFrEF - new dx.  EF 35-40% (EF 60% 11/2021).  LV wall motion abnormal.  Negative troponin x 1.  EKG with T waves changes (but with recent CVA hx).  Presented with uncontrolled hypertension with uncontrolled AF.  BP now controlled with losartan 100 mg daily + metoprolol 25 mg.  HR high normal.  Euvoelmic on exam with DOE; given 100 mg IV lasix yesterday.  Urine output 2.5 L overnight. Creatinine stable 0.82.     2.  AF - persistent.  Controlled with digoxin 250mcg daily + toprol 25 mg daily.  CHADSVASC (age x 2, HTN, CHF, CVD, DMII); On apixaban 5mg BID.     3.  PAD - bilateral cartoid disease - s/p endartectomy x2 12/2021 and then 2/2022.  Allegedly received a PCI stent in the past; unable to find records; patient believes it is at health.  On atorvastatin 80 mg daily + ASA 81mg daily.  Follows with Doctor.    4.  NSVT - 21 beat run this AM.    5.  COVID - 19 -clinically asymptomatic.  Incidental finding.  Today, patient states he wishes to leave the hospital.  He was frustrated with not being able to sleep well during the night and felt it was difficult obtaining sleep medicine.  He agrees to a home oxygen evaluation.  Given the fact that the patient failed outpatient therapy with 20 mg of daily Lasix, I feel it is reasonable to discharge him on 40 mg of Lasix daily along with the 12.5 of spironolactone with close follow-up hopefully next week in the cardiology clinic.  I recommended that he follow-up with the cardiology clinic next week if possible and discharged him on the current dose of metoprolol XL 75 mg p.o. daily, losartan, as well as digoxin that he was taken PTA.  In addition I ordered spironolactone 12.5 mg daily to be started per the recommendation of cardiology.  I also gave him the number to obtain a new primary care provider.  Patient will be discharged on Eliquis along with the PTA aspirin and Plavix due to his bilateral carotid disease.   Acute hypoxic respiratory failure due to COVID 19 pneumonia along with acute systolic heart failure heart failure. Admission procalcitonin less than 0.04.  Thus doubt bacterial pneumonia 2/18 CRP 5.4 patient was weaned to room air 2/19 patient on 1 L CRP improved to 3.6.  Patient agrees to discharge on dexamethasone 6 mg daily for 3 days to treat his wheezing and improve his respiratory status.  The patient was screened by respiratory therapy for home oxygen on the day of discharge.  His room air sat at rest was 97% with exertion his lowest sat was 93%.  He did not qualify for home oxygen.   Chronic atrial fibrillation with RVR.   Patient is heart rate has improved.  This is managed by cardiology as noted above And the patient will discharge home on the medications listed below.   Nonsustained V. tach 2/18 patient had at 21 feet of nonsustained V. tach.  Cardiology team increase the metoprolol XL to 75 mg daily   Diabetes.  continue PTA Lantus and NovoLog with medium intensity sliding scale.  A1c 8.4   CVA.  Continue aspirin, plan and cholesterol medication   Hypertension.  Treat with metoprolol XL and continue PTA losartan as stated above.