Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Non-immune heparin associated thrombocytopenia, Obesity, Oedema peripheral, Percutaneous coronary intervention, Peripheral swelling
Clinical narrative: COVID Vaccine Breakthrough Case;Pfizer Dose 1 3/30/21 (ER8727); Pfizer Dose 2 4/21/21  (ER8731); COVID Positive 9/10/21:Chief Complaint: pt c/o generalized weakness and cough. History of Present Illness. 75-year-old male with coronary artery disease status post PCIs, hypertension, hyperlipidemia, type 2 diabetes mellitus complicated by diabetic nephropathy, morbid obesity and Reiter's syndrome presented with generalized weakness.  patient reported has been progressively getting weak, felt like his knees were about to give out and having cough, shortness of breath nasal congestion.  He has chronic leg swelling worse on the right side, no orthopnea PND.  Patient reported recently has been spending most of the time sitting only getting up to get  drinks or snacks. Denies any previous history of PE or DVT.  Had colonoscopy about 2 months ago  was told he had a precancerous polyp. Denies any recent surgery, long distance travel or i hospitalization.  He had been vaccinated for COVID-19.  He is maintaining normal oxygenation on room air and hemodynamically stable.  Has elevated D-dimer, CT chest PE protocol showed right-sided  pulmonary embolism with no right heart strain.  Patient has been started on heparin GTT.Review of Systems. Ten point review of systems negative except above.Physical Exam:Vitals & Measurements:T: Warm(Skin)  TMIN: 36.8  °C (Tympanic)  TMAX: 100.5  °F HR: 65(Peripheral)  RR: 17  BP: 136/70  SpO2: 95%  HT: 182.9 cm  WT: 160.5 kg. General appearance:  Patient is lying in bed does not appear to be in cardiopulmonary distress. HEENT:  PERRLA. Lungs:  Poor bibasilar air entry no rales no wheezing or accessory muscle use Heart:  S1 and S2 well heard there is no murmur or gallop. Plus two pedal and pretibial edema. Abdomen:  Soft, nondistended nontender.Skin:  erythema over the abdominal folds. Extremities:  No obvious deformities. Neuro: Conscious and alert.Assessment/Plan:Right-sided pulmonary embolism, no  heart strain. Dyspnea on exertion, Deconditioning,Morbid obesity,Coronary artery disease status post PCIs, stable,Type 2 diabetes mellitus,Essential hypertension and hyperlipidemia,CKD stage 3, at baseline, Reiter's syndrome, Acute urinary retention. Plan: Heparin drip PE protocol, pulmonary  embolism likely provoked by sedentary lifestyle.  Follow-up COVID-19 PCR. Patient is also  D condition, needs PTOT  Plavix, atorvastatin, metoprolol and Lasix. Telemetry monitoring, Hold glimepiride, mild correction scale Humalog, Foley catheter placed for acute urinary retention, Continue rest of home medications as appropriate, Code Status: Full code. Discharge Diagnosis, Date of admission 09/10/2021; Date of discharge 09/17/2021. Acute provoked none massive pulmonary embolisms due to COVID infection and sedentary lifestyle. Acute COVID-19 infection, moderate, improved Sepsis due to UTI and COVID infection, improved. Possible CAP. Acute hypoxic respiratory failure does not require ventilator due to COVID-19 infection and PE, improved. NSVT due to respiratory distress, resolved. Acute non massive hemoptysis while on anticoagulant with mild thrombocytopenia, resolved. Complicated E. coli UTI, treated, Acute urine retention, resolved  Acute mild thrombocytopenia with non massive hemoptysis, mostly due to COVID-19 infection and HIT type 1,Deconditioning,Morbid obesity,CAD s/p DES,Type 2 diabetes mellitus, controlled  Essential hypertension, controlled,Hyperlipidemia,CKD stage 3, at baseline, Reiter's syndrome Hospital Course:75-year-old male with coronary artery disease status post PCIs, hypertension, hyperlipidemia, type 2 diabetes mellitus complicated by diabetic nephropathy, morbid obesity and Reiter's syndrome presented with generalized weakness.  Patient was then diagnosed the right-sided pulmonary embolism without heart strain, dyspnea on exertion, deconditioning with on top of previous comorbidities.  Patient was started with heparin drip. Patient was then found to have COVID-19 infection.  Patient was treated with IV antibiotics, remdesivir and dexamethasone.  Patient general condition significantly improved and anticoagulation was switched to Eliquis and discharged to SNF to follow-up with PCP and hematology oncologist as outpatient.  Patient had episodes of bradycardia and beta-blockers were discontinued and ACE inhibitors were started. Physical Exam;Vitals & Measurements T: 97.3  °F   TMIN: 35.8  °C (Tympanic)  TMAX: 98.3  °F HR: 60(Peripheral)  RR: 20  BP: 166/81  SpO2: 98%. General: Alert and oriented, well nourished, no acute distress.Eye: PERRL, normal conjunctiva.HENT: Normocephalic, normal hearing, moist oral mucosa, no scleral icterus.Neck: Supple, non-tender, no carotid bruits, no JVD, no lymphadenopathy.Lungs: Good bilateral air entry, mild wheezing and prolonged expiration with mild crepitation.Heart: Normal rate, regular rhythm, no murmur, gallop or edema.Vascular system: Pulses are palpable, no lower limbs edema, tenderness or swelling.Abdomen: Soft, non-tender, distended, normal bowel sounds, no masses palpable.Musculoskeletal: Normal range of motion and strength, no tenderness or swelling.Skin: Skin is warm, hyperemic skin rash over the inguinal fold. Neurologic: Awake, alert, and oriented X3, CN II-XII intact, no focal weakness.Psychiatric: Cooperative, appropriate mood and affect.Home Medications (19) Active  Acetaminophen 650 mg, PRN, PO, Q4Hours;Acetaminophen-Hydrocodone 325 mg-5 mg oral tablet 2 Tab, PRN, PO, Q4Hours; Apixaban 5 mg oral tablet 10 mg = 2 Tab, PO, BID (Twice Daily)  Apixaban 5 mg oral tablet 5 mg = 1 Tab, PO, BID (Twice Daily); Ascorbic acid 500 mg oral tablet 500 mg = 1 Tab, PO, DailyWM (Once Daily With A Meal); Aspirin 81 mg oral delayed release tablet 81 mg = 1 Tab, PO, Daily (Once Daily); Atorvastatin 10 mg oral tablet See Instructions  Cholecalciferol 1000 intl units oral capsule 25 mcg = 1 Cap, PO, Daily (Once Daily); Famotidine 20 mg oral tablet 20 mg = 1 Tab, PO, HS (At Bedtime); Fenofibrate 160 mg oral tablet 1 Tab, PO, Daily (Once Daily); Furosemide 40 mg, PO, Daily (Once Daily); Gabapentin 300 mg oral capsule 1 Cap, PO, TID (Three Times Daily); Glimepiride 4 mg oral tablet 1 Tab, PO, Daily (Once Daily)Losartan 25 mg oral tablet 25 mg = 1 Tab, PO, Daily (Once Daily); Nitrostat 0.4 mg sublingual tablet 0.4 mg, PRN, Sublingual, Q5Min-Interval;Nystatin 100,000 units/g topical powder 1  Application, Topical, TID (Three Times Daily); Potassium chloride 20 mEq, PO, Daily (Once Daily)Probenecid 500 mg, PO, BID (Twice Daily); Uloric 80 mg, PO, Daily (Once Daily); Discharge Plan Continue anticoagulation; Follow-up with PCP, hematologist and cardiologist as outpatient:Patient Discharge Condition:Stable:Discharge Disposition. I spent 35 minutes planning and coordinating discharge of the patient. Discharge Instructions;Opioid Discharge Instructions (Custom)follow-up with contact information. Additional Instructions: D/C Skilled. Go through ED entrance.