Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Anion gap, Anticoagulant therapy, Asthenia, Blood bicarbonate decreased
Clinical narrative: Hospitalized (1.24.22 - 1.25.22),  COVID-19 positive (1.11.22); Fully vaccinated PLUS Booster - pfizer x3 D/c summary:Discharge Summary , PA-C (Physician Assistant-Certified) ? ? General Medicine Cosigned by:  MD at 1/31/2022  9:30 AM  BRIEF OVERVIEW: Discharge Provider:  MD Primary Care Provider:  DO Admission Date: 1/24/2022 Discharge Date: Jan 25, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? Dyspnea due to COVID-19 01/24/2022 Yes ? Exercise-induced asthma 12/30/2020 Yes ? Class 2 severe obesity due to excess calories with serious comorbidity and body mass index (BMI) of 35.0 to 35.9 in adult (HCC) 08/02/2021 Yes ? Type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin (HCC) 01/08/2020 Yes ? Hypothyroidism   Yes ? Hypertension   Yes ? Hyperlipidemia   Yes ? GERD (gastroesophageal reflux disease)   Yes ? OSA (obstructive sleep apnea)   Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Elevated d-dimer 01/24/2022 01/25/2022 Yes ? Elevated troponin 01/24/2022 01/25/2022 Yes ? AKI superimposed on Stage 3b chronic kidney disease (HCC) 09/13/2021 01/25/2022 Yes ? Hyperkalemia 01/25/2022 01/25/2022 Yes ? Hyponatremia 01/08/2020 01/25/2022 Yes Discharge Disposition:  home or self care    Active Issues Requiring Follow-up: PCP regarding difficulty breathing and blood pressure    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Paroxysmal tachycardia (HCC)  AKI (acute kidney injury) (HCC)  Dyspnea, unspecified type  Dyspnea due to COVID-19   HOSPITAL COURSE: Patient is a 66 y.o. male who presented to ER op 1/24 with dyspnea. He started with COVID symptoms on 1/5 an was tested 1/11 which was positive. He had aches and pain, sore throat, temp of 102 and cough initially. On 1/18 he started to have worsening trouble breathing and heart racing with activity. He denied palpitations or chest pain. He had SOB at rest but worse with activity and continued to have occasional cough. He is vaccinated and boosted. He has no prior history of blood clot or arrhythmia.    In the Er he had CXR that was negative for acute process. Due to his renal function unable to have a CTA chest. He had ddimer of 800 in the ER with recent COVID illness. Vitals were stable in the ER and EKG showed sinus tachycardia. He was on room air in the ER. He was given IVF, albuterol and decadron. After he received albuterol in the ER he felt that his wheezing and SOB had improved. He was admitted for Perfusion study and further work up of dyspnea. His NM study was normal today and no need for anticoagulation at this time. He had AKI in the ER and his aldactone, HCTZ and lisinopril were held. He had some elevated blood pressure in the ER and again overnight. He received IV metoprolol and hydralazine with improvement. He had some elevated K this morning and received lokelma with improvement of his potassium. Will avoid aldactone at discharge but will follow up with PCP. Cr was also improved at time of discharge to 1.57 from 2.01 on admit. Due to his dyspnea an ECHO was completed today showing EF 59% and normal right ventricle. No AS and no wall motion abnormalities noted. Given that his dyspnea improved with albuterol it is likely COPD exacerbation secondary to his recent COVID pneumonia. Recommend outpatient follow up with pulmonology. Patient is clinically improved and hemodynamically stable for discharge.  Discussed plan of care for discharge with patient including outpatient follow-up with PCP within 7 days.  Patient voiced understanding and was agreeable with plan of care for discharge.   CONSULTS / RECOMMENDATION: None INPATIENT PROCEDURES: None  BP 159/82  | Pulse 75  | Temp 36.6 °C (Oral)  | Resp 18  | Ht 1.829 m  | Wt 119.1 kg  | SpO2 98%  | BMI 35.61 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is well-developed. He is obese.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Neck:     Thyroid: No thyromegaly.     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: No murmur heard.     Comments: No lower extremity edema Pulmonary:     Effort: No tachypnea or respiratory distress.     Breath sounds: Normal breath sounds. No wheezing, rhonchi or rales.     Comments: Lungs clear, he is on room air  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Speech: Speech normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.   H&P:  Hospitalist H&P   CHIEF COMPLAINT: Dyspnea due to COVID-19   CODE STATUS:Full code no prolonged life support  DVT prophylaxis: Lovenox Sub Q Patient was admitted on 1/24 for Dyspnea ASSESSMENT/PLAN:   * Dyspnea due to COVID-19 Assessment & Plan Recent COVID infection with 20 days of symptoms and COVID positive 9 days ago Patient had CXR in the ER negative for acute process. He is vaccinated Due to his dyspnea and tachycardia ER was concerned for PE. Ddimer 800 but unable to do CTA Will admit and obtain VQ perfusion study tomorrow to rule out PE Continue supportive care Started on decadron in the ER, consider continuing despite no hypoxia He is on room air in the ER     Elevated d-dimer Assessment & Plan With recent history of COVID and elevated d-dimer (though minimally elevated at 800) concern for PE He is unable to have CTA chest due to his renal function  He is currently on room air but us having some dyspnea and tachycardia at times CXR showed no acute findings Due to recent COVID unable to do complete VQ scan but can do perfusion study  He does have slightly elevated troponin but normal BNP.  Place on Sub Q lovenox for now and start therapeutic treatment pending VQ scan or worsening respiratory state   Elevated troponin Assessment & Plan Troponin 47-- >63 in the ER ER reviewed with Cardiology who recommended trending troponin and monitoring EKG showed Sinus tachycardia with some slight Twave inversion in V1 and V2 Continue to monitor closely  Consult cardiology if worsening Per Er discussion with cardiology, dont do stress test until we know he is negative for PE Consider ECHO tomorrow if PE noted Consider need for stress test pending VQ scan given dyspnea, tachycardia and recent COVID illness    AKI superimposed on Stage 3b chronic kidney disease (HCC) Assessment & Plan Cr appears worse than baseline today was 2.7 today and was 2.2 4 months ago  Continue to monitor renal function closely and renally dose medications as needed Hold lisinopril, aldactone and HCTZ for now and resume when appropriate Given IVF in the ER, continue    Exercise-induced asthma Assessment & Plan Dyspnea in the ER and concern for possible asthma related reaction  No wheezing on exam, hold additional steroids and consider if worsening respiratory state  He does have long smoking history though now doesn't smoke ? Component of COPD Given dose of decadron in the ER, hold for now  Continue albuterol and flovent    Class 2 severe obesity due to excess calories with serious comorbidity and body mass index (BMI) of 35.0 to 35.9 in adult (HCC) Assessment & Plan Encourage weight loss and lifestyle modifications for improved overall health    Hyponatremia Assessment & Plan Na 127 today and even with correction for hyperglycemia it is still low Given IVF in the ER, continue gentle IVF and avoid overload  Continue to monitor closely, repeat lab this evening  Holding HCTZ for now    Type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin (HCC) Assessment & Plan Hold metformin and ozempic  Place on 24 hour corrective insulin and adjust as needed Continue to monitor blood sugar    GERD (gastroesophageal reflux disease) Assessment & Plan Continue PPI   Hyperlipidemia Assessment & Plan Continue statin    Hypertension Assessment & Plan BP elevated in the ER Continue Clonidine, and metoprolol Due to mild worsening of renal function hold lisinopril-HCTZ today  Continue to monitor blood pressure and adjust meds as needed    Hypothyroidism Assessment & Plan Continue levothyroxine    OSA (obstructive sleep apnea) Assessment & Plan Continue home CPAP or night oxygen PRN Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 66 y.o. male who presents today with dyspnea. He notes that he started to "feel like I had something like COVID on 1/5." he states that he had aches and pain, sore throat, temp of 102 and cough. He notes that he was able to get a COVID test at a vaccination center on 1/11 and he got the results back from that on 1/16 and it was positive. He notes that on 1/18 he started to have worse trouble breathing. He states "it takes very little exercise to make my heart pump hard." He notes that after taking a shower this morning his heart rate was in the 130s and he states "it has been like that for a week if I do anything." He can feel his heart racing and he states "I can feel it in my ears." He denies palpitations or chest pain. He notes that he is a little SOB just at rest but worse with activity. He is also coughing still. He notes that a week ago he was very congested and he was taking mucinex. He notes that he did albuterol in the ER but that helped to get stuff broken up. He notes that normally his HR is in the 70s and at home his blood pressures were in the 130s systolic but here he is having high blood pressure. He has had weakness and fatigued but is eating ok. He denies prior history of blood clot. He has not had pain or swelling in his legs. He denies prior cardiac history of arrhythmia. He notes that his son and wife both had COVID around the same time. He is vaccinated and boosted.    In the Er he had CXR that was negative for acute process. Due to his renal function unable to have a CTA chest. He had ddimer of 800 in the ER with recent COVID illness. VQ scan ordered for tomorrow. Vitals were stable in the ER and EKG showed sinus tachycardia. He was on room air in the ER. He was given IVF, albuterol and decadron. He will be admitted to the hospitalist service for observation and VQ scan tomorrow with close monitoring of his dyspnea.  Review of Systems Constitutional:  Positive for fatigue. Negative for appetite change, chills and fever.       He had fever and chills initially but nothing since 1/12.  HENT: Positive for rhinorrhea. Negative for congestion and sore throat.       Sores in his mouth a few weeks ago but gone now.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough, wheezing, shortness of breath, chest tightness and sputum production.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation, diarrhea and blood in stool.  Genitourinary:  Positive for difficulty urinating. Negative for dysuria and hematuria.  Musculoskeletal:  Negative for joint pain and muscle pain.       Initially achy but better now.  Neurological:  Positive for weakness (generalized). Negative for headaches and dizziness.  Endo/Heme/Allergy:  Positive for easy bleeding or bruising.  Psychiatric/Behavioral:  Negative for depression and anxiety.  Skin:  Negative for rash and wound.  OBJECTIVE: BP 178/89  | Pulse 100  | Temp 36.6 °C (Oral)  | Resp 18  | Ht 1.829 m  | SpO2 100%  | BMI 34.88 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is well-developed. He is obese.     Comments: Appears comfortable lying in bed with wife at bedside   HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.     Comments: No sores in his mouth at this time  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Comments: Right eyelid slightly lower than left   Neck:     Thyroid: No thyromegaly.     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: No murmur heard.     Comments: No lower extremity edema Pulmonary:     Effort: Pulmonary effort is normal. No tachypnea or respiratory distress.     Breath sounds: Normal breath sounds. No wheezing, rhonchi or rales.     Comments: Lungs slightly diminished but otherwise clear, No wheezing or rhonchi. He is on room air and no coughing on exam Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Speech: Speech normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.