Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Abdominal distension, Abdominal pain upper, Abdominal tenderness, Angina unstable, Anion gap
Clinical narrative: Hospitalized (1.15.22 -1.17.22); COVID-19 positive (1.1.22- home test 1.14.22 hospital confirmed); fully vaccinated PLUS Booster - Moderna x3. D/C summary: Discharge Summary: PA-C (Physician Assistant-Certified) Cardiology. BRIEF OVERVIEW: Discharge Provider: MD, Primary Care Provider: MD. Admission Date: 1/15/2022, Discharge Date: 01/17/2022. Presenting Problem: Unstable angina pectoris (HCC). Active Hospital Problems: Diagnosis: Date Noted: POA: Unstable angina pectoris (HCC) 01/17/2022 Unknown. Resolved Hospital Problems: Diagnosis Date Noted Date Resolved POA. Other chest pain 12/10/2021 01/17/2022 Unknown. The patient's most recent ejection fraction per echo was: Lab Results: Component Value Date: EJECFRACECHO 67 01/15/2022. At discharge, the following medications/referrals/education was given/prescribed: Aspirin was prescribed/continued. Beta Blocker was prescribed/continued. ACEI / ARB / ARNI not needed as LV ejection fraction was within normal range. Statin was prescribed for this patient with CAD. LDL goal is less than 70 mg/dL. No smoking cessation applicable; the patient does not smoke. Cardiac Rehab referral was placed; the patient will be contacted to set this up and Cardiac Rehab not indicated for this patient. Discharge Disposition: Home without services. Active Issues Requiring Follow-up: Changes in Medications at Discharge: See below: DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 68 y.o. male patient of Dr. with history of CAD, s/p 3V CABG, type 2 diabetes, hypothyroid, hypertension, dyslipidemia, history of hepatitis C, alcohol abuse with cirrhosis and requiring prior paracentesis. He had a recent nuclear stress test that was negative for ischemia. He presented to the ER 1/15 for complaints of 3 day history exertional chest pain and weight gain. He ruled out for ACS. Echocardiogram revealed preserved biventricular function. Abdominal US showed minimal ascites. He then underwent invasive coronary angiography that showed severe CAD, 3/3 patent bypass grafts, and a first diagonal isolated from any bypass graft without significant retrograde flow from the LIMA graft, and is being supplied by the native LAD which has a 90 % lesion. Intervention would probably require atherectomy. An initial approach of increased medical therapy was undertaken by increasing Toprol to 50 mg twice daily and adding Imdur 30 mg daily. With this he had no further angina with ambulation. If he fails medical therapy in the future a trial of dual anti-platelet agents prior to stent placement is recommended to sure that he will not develop any further GI bleeding. CONSULTS: None. INPATIENT PROCEDURES: Surgery and Procedures: Past Procedures (1/15/2022 to Today). Date Time Procedures: Providers 01/16/2022 1200 CV LEFT HEART CATHETERIZATION, CORONARY ANGIOGRAM. Non-surgical Procedures (From admission, onward) None. BP 130/62  | Pulse 78  | Temp 36.5 °C (Oral)  | Resp. 18  | HT 1.829 m  | WT 90.6 kg  | SpO2 100%  | BMI 27.09 kg/m². Physical Exam: Constitutional: General: He is not in acute distress. Appearance: He is well-developed. He is not diaphoretic. HENT: Head: Normocephalic and atraumatic. Mouth/Throat: Pharynx: No oropharyngeal exudate. Eyes: General: Right eye: No discharge. Left eye: No discharge. Conjunctiva/sclera: Conjunctivae normal. Neck: Thyroid: No thyromegaly. Vascular: No JVD. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Heart sounds: No murmur heard. No friction rub. No gallop. Comments: Right radial artery uncomplicated, soft, post-cath. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal breath sounds. No rales. Chest: Chest wall: No tenderness. Abdominal: General: Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. There is no mass. Tenderness: There is no abdominal tenderness. Musculoskeletal: General: No tenderness or deformity. Normal range of motion. Cervical back: Normal range of motion and neck supple. Skin: General: Skin is warm and dry. Coloration: Skin is not pale. Findings: No erythema or rash. Neurological: Mental Status: He is alert and oriented to person, place, and time. GCS: GCS eye sub score is 4. GCS verbal sub score is 5. GCS motor sub score is 6. Psychiatric: Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal. H&P: Attestation signed by attending MD at 1/16/2022 12:05 PM. I have personally interviewed and examined the patient on 1/16/2022. Management was discussed with cardiovascular team. I agree with the documented findings and plan of care in his/her note. Brief exam: Patient is no acute distress. Cardiovascular exam is unremarkable. Brief history and medical decision making:  Patient presents with exertional chest discomfort shortness of breath nausea. That this chest discomfort is similar to what he had had prior to his bypass. He was diagnosed with COVID on January 1st after a family get together for Christmas, His stress test was unremarkable previously for similar symptoms. Therefore believe we should proceed with cardiac catheterization to rule out any cardiac etiology of his symptoms. This was discussed with the patient he is in agreement. He does seem to recovering well from his COVID.  He will finish out the course of his steroids. Expand All Collapse All. Hide copied text, Hover for details, Interventional Cardiology. CHIEF COMPLAINT: Other chest pain. ASSESSMENT / PLAN: Symptoms concerning for unstable angina versus other causes such as hypervolemia/recurrent ascites. Continue metoprolol and statin. Add daily aspirin. He has not had any further chest discomfort. Repeat troponin to trend as well as check NT proBNP. If troponin continues to rise would start heparin.  His weight is up 3.8 kg compared to discharge weight following prior paracentesis. His belly is distended along with elevated JVP, will repeat echocardiogram and abdominal ultrasound. Potentially plan invasive coronary evaluation pending above workup. Exertional anginal quality chest pain, rule out ACS-MPI 12/10: no ischemia -HsTnT 13, 13, 23. Coronary artery disease-s/p CABG 8/2021 (free LIMA to LAD, vein graft to OM and ramus). Anemia of chronic disease, Acute on chronic Thrombocytopenia-HDA and SRA negative 9/2021-occult negative 1/15-baseline HGB 9-10, PLT 120-130. Esophageal varices. ETOH/cirrhosis/Ascites -s/p paracentesis 12/2021 2.7L drained-EGD 10/2021 varices banded, were not bleeding. COVID-19 positive, initially on Jan. 1-started steroids 1/10 (10-day course). Previously vaccinated and boosted -afebrile, CXR without consolidation. Diabetes Mellitus -metformin at home-elevated BG on admission (on steroids) -BBI SS inpatient. DVT prophylaxis: Early and progressive mobility I am admitting this patient to Inpatient because of complex medical history now presents with unstable symptoms potential multiple etiologies requiring further workup. SUBJECTIVE: Patient is a 68 y.o. male patient of Dr. with complex history of CAD, s/p 3V CABG 8/21, type 2 diabetes, hypothyroid, hypertension, dyslipidemia, history of hepatitis C, alcohol abuse with cirrhosis. Postop CABG course complicated by provoked PE, recurrent pleural effusions requiring thoracenteses, anemia/thrombocytopenia of unclear etiology. He was admitted in October for hematemesis and acute anemia requiring transfusions, source from newly discovered esophageal varices that were banded. From this point Eliquis OAC was discontinued given risk/benefit. In December as an outpatient he was found to have significant ascites and underwent paracentesis draining 2.7 L. Following this he presented to the ER for complaints of anginal quality chest discomfort, ruled out for ACS and nuclear stress test negative for ischemia. He was diagnosed with symptomatic COVID-19 infection 1/1 and has been treated with 10 day course of steroids which he currently remains on. He presented back to the ER today for complaints of 3 day history exertional chest pain. He initially felt symptoms on Wednesday as he was walking to his mailbox that he describes as left flank discomfort with radiation down to his left elbow associated with nausea, shortness of breath, diaphoresis and emesis. Symptoms resolved with rest within about 30 minutes. On Thursday he had another episode just walking through his house, as well as on Friday same situation which prompted him to seek care. He denies any rest onset symptoms. He stated if he he did not have nausea and vomiting with these episodes he would have not come in. He has been compliant with his medications. Denies any recurrent known bleeding events. He checks his weight at home and believes it to be quite stable. He denies edema, orthopnea. He has chronic RUQ pain and abdominal distension that is unchanged. In the ER his symptoms resolved after 2nd nitroglycerin. He told me he ambulated again in the ER and had recurrent pain which resolved with nitroglycerin. Chest x-ray without acute process recurrent effusions. EKG without acute ischemia. Troponin up to 20's therefore transferred for further evaluation. He has not had any recurrent pain. Occult blood negative. I have reviewed pertinent past medical, surgical, family and social history, as well as allergies and current medications. See below. Review of Systems: A 10-point review of systems was completed and all other review of systems negative unless stated above in the HPI. OBJECTIVE: BP 153/74  | Pulse 97  | Temp 36.3 °C (Oral)  | Resp. 20  | Ht 1.829 m  | Wt 91.4 kg  | SpO2 99%  | BMI 27.33 kg/m². Physical Exam: Constitutional: General: He is not in acute distress. Appearance: He is well-developed. He is not diaphoretic. HENT: Head: Normocephalic and atraumatic. Mouth/Throat: Pharynx: No oropharyngeal exudate. Eyes: General: Right eye: No discharge. Left eye: No discharge. Conjunctiva/sclera: Conjunctivae normal. Neck: Thyroid: No thyromegaly. Vascular: JVD present. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Heart sounds: No murmur heard. No friction rub. No gallop. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal breath sounds. No rales. Chest: Chest wall: No tenderness. Abdominal: General: Abdomen is protuberant. Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. There is no mass. Tenderness: There is abdominal tenderness in the right upper quadrant. Musculoskeletal: General: No tenderness or deformity. Normal range of motion. Cervical back: Normal range of motion and neck supple. Skin: General: Skin is warm and dry. Coloration: Skin is not pale. Findings: No erythema or rash. Neurological: Mental Status: He is alert and oriented to person, place, and time. GCS: GCS eye sub score is 4. GCS verbal sub score is 5. GCS motor sub score is 6. Psychiatric: Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal.