Age: 95.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Atrial fibrillation, Blood pressure decreased, Blood thyroid stimulating hormone decreased, COVID-19
Clinical narrative: BRIEF OVERVIEW: Admission Date: 1/3/2025 Discharge Date: Jan 6, 2025 Discharge Disposition:  home health care svc   Active Issues Requiring Follow-up:    1) Follow-up ongoing management of paroxysmal atrial fibrillation with admission for atrial fibrillation with rapid ventricular rate with addition of amiodarone to home beta-blocker with planned close follow up with Cardiology; 2) follow-up resolution of COVID-19 upper respiratory viral symptoms with patient having no evidence of hypoxia during admission with viral illness treated with supportive care only; 3)follow-up history of hypertension, chronic heart failure with preserved EF and pulmonary hypertension, discontinued home Amlodipine and changed home diuretic to as needed for lower extremity edema in setting of acute viral illness, once patient has stabilized and if blood pressure is consistently elevated consider restarting scheduled loop diuretic with low dose mineralocorticoid antagonist (I.e., Torsemide 20 mg daily + Spironolactone 12.5 or 25 mg daily in lieu of restarting Amlodipine targeting heart failure with preserved EF and lower extremity edema; 4) follow up abnormal thyroid studies with low TSH, mildly high free T4 and low T3 - discuss with endocrinology with recommendation for repeat TSH free T4 and T3 in 4 weeks and if free T4 and T3 are elevated patient likely will need antithyroid medications, recommend referral to endocrinology if thyroid studies remain abnormal (discuss this with patient's primary care provider, Dr) DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypomagnesemia [E83.42] Generalized weakness [R53.1] Atrial fibrillation with RVR (HCC) [I48.91] Atrial fibrillation, unspecified type (HCC) [I48.91]  HOSPITAL COURSE: Patient presented with progressive generalized weakness with upper respiratory viral symptoms found to be in atrial fibrillation with rapid ventricular rate in the setting of known paroxysmal atrial fibrillation.  Full respiratory viral PCR panel was positive for COVID-19 although initial testing was negative.  Viral symptoms were treated with supportive care including Mucinex and cough suppressants.  Patient had no evidence of hypoxia during admission and had peripheral oxygen saturations in the high 90s on room air at time of discharge requiring no treatment for COVID-19.  With respect to patient's atrial fibrillation with rapid ventricular rate, patient was started on amiodarone bolus and infusion with IV heparin transitioned back to home oral rivaroxaban.  Patient converted to normal sinus rhythm in amiodarone infusion was transitioned to amiodarone 200 mg 2 times a day in the hospital with discharged on amiodarone 200 mg daily in addition to patient's home metoprolol tartrate 25 mg 2 times a day.    Patient was initially started on IV diuretics in the setting of elevated proBNP of 9866 but had signs of hypovolemia including worsening kidney function with mildly low blood pressures and in the setting of COVID-19 viral illness, diuretics were discontinued and patient was given a small IV fluid bolus.  Patient had no clinical signs of decompensated heart failure after resolution of tachyarrhythmia.  Repeat echocardiogram showed preserved left ventricular ejection fraction, indeterminate diastolic dysfunction and pulmonary hypertension.  Patient was  given IV magnesium for hypomagnesemia and given dose of IV iron sucrose for iron-deficiency anemia.  Patient was encouraged to drink more water as family reports her fluid intake is typically poor.  Patient's home Amlodipine was discontinued. Her home scheduled diuretics were changed to prn for fluid retention.    On separate note, patient has significant carotid atherosclerotic disease and was restarted on low-dose aspirin daily as she has a strong indication for antiplatelet therapy.  Patient was counseled to avoid all fish oil and cod liver oil as both can cause bleeding.  She was also tinnitus to avoid any over-the-counter adult aspirin products or NSAIDs as they also can precipitate bleeding.  On separate note patient had a low TSH and mildly elevated free T4.  T3 was checked and was low.  Typically with hyperthyroidism we would expect that T3 to be high.  Discussed with endocrinology and they recommended repeating thyroid studies including TSH, free T4 and T3 in 4 weeks and if TSH remains low with elevated free T4 and T3 patient likely might need antithyroid medications.  If 3rd said he has remain abnormal recommend referral to endocrinology.  Discharged to Home Health Care