Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: Sinus arrhythmia, Swallow study, Troponin, Wheezing
Clinical narrative: Pfizer Dose 1 2/26/21 (EN6203) Pfizer Dose 2 3/24/21 (ER2613) Pfizer Dose 3 10/27/21 (FF2593) COVID Positive 3/5/22  3/5/22:  Pt is an 82 year old male with a past medical history of HTN, Hx CVA, COPD, HLD, GERD, BPH, Anxiety, Depression and schizoaffective disorder who presents to the ED with chest pain.  Patient states for the past 3 afternoons and nights he has been experiencing substernal chest pain that occasionally radiates into his back.  Denies radiation to neck, jaw, arm.  He describes the pain is dull and it is intermittent, every 3-4 minutes. He is not currently experiencing the chest pain.  He states that he has not tried anything to relieve the pain in the only intervention he has made is coming to the hospital today.  He did state that he had this exact same pain when he was in his 30s or 40s and was eliminated after 2 chiropractic adjustments.  He does state that is also similar to times when he has had episodes of acid reflux. He does note that the substernal chest pain is often associated with increased gas, belching, epigastric abdominal pain.  Generally after lunch he lays down within 10 minutes of eating and within 2-3 hours after dinner. Patient followed with a cardiologist in the 90s and had a stress test done at that time. Patient states that his stress test was negative.  Denies history of stents.  Patient was recently diagnosed with COVID-19 on February 17th and he quarantine until February 26. He states that since this time he has had a dry nonproductive cough.  In addition to the symptoms patient also endorses chronic right knee pain which he was told is due to arthritis.   In the ED patient was hypertensive 155/71.  Labs were remarkable for K 5.3, Glc 108, Mag 2.7, troponin negative x2, hgb 12.2.  EKG normal sinus rhythm with sinus arrhythmia unchanged from previous.  CXR remarkable for low volumes with no acute cardiopulmonary process.  No medications were given in the emergency department.  3/14/22: Pt is an 82 year old male with pmh HTN, hx CVA with residual left sided weakness, COPD, HLD, GERD, BPH, schizoaffective disorder that was admitted on 3/5 for ACS rule out given a 3 day history of substernal chest pain radiating to his back with occasional shortness of breath. He had also been experiencing bloating, gas and epigastric abdominal pain. Of note, he tested positive for COVID on 2/17 at his long term care facility.   ED course per EMR review: "hypertensive at 155/71.  Labs were remarkable for K 5.3, Glc 108, Mag 2.7, troponin negative x2, hgb 12.2.  EKG normal sinus rhythm with sinus arrhythmia unchanged from previous.  CXR remarkable for low volumes with no acute cardiopulmonary process.  No medications were given in the emergency department."   Cardiology was consulted for this case and stress test was performed on 3/7. This showed apical anteroseptal and apical inferolateral walls. He was planned to go to the cath lab, however due to leukocytosis and intermittent fevers, this was held off. Echo was performed and was overall unremarkable with an EF of 68%. His blood cultures grew E. coli and antibiotics were adjusted accordingly. Source of infection was sought out, CT chest was unremarkable, so CT abdomen was obtained on 3/8. When this showed probable acute cholecystitis, surgery was consulted. A HIDA scan was recommended and, when this confirmed acute cholecystitis, a cholecystostomy drain was recommended given patient's cardiac status. This was placed without complication on 3/8. Shortly after this was placed, a rapid response was called due to patient experiencing respiratory distress. Patient never desaturated, however high flow oxygen and bipap was placed for patient comfort. Stat labs and plan films of chest and abdomen were all unremarkable. Patient did have wheezing, so prn albuterol nebulizer treatments were administered. With the drain in place and antibiotics on board, patient continued to clinically improve with resolution of leukocytosis and fevers. His abdomen was sore over the site of the drain, but the epigastric pain resolved. General surgery recommended cholecystectomy in 3 months after cardiac intervention was completed and patient remained stable. Patient was subsequently taken to the cath lab on 3/10 and a bare metal stent was placed in the LAD. This was done in part so patient could be placed on Brilinta for 1 month and aspirin for life and cholecystectomy can be performed in 3 months as planned. There was concern for patient aspirating and having difficulty swallowing following the cath, however speech was consulted. A swallow study was performed, was normal, and patient was able to eat on his own. Per patient and his daughter, this has been happening occasionally since his CVA last summer, however he has never aspirated to their knowledge.   His chronic conditions were managed with home medications. Lisinopril for HTN was held due to hyperkalemia, and Amlodipine was started when BP became mildly elevated. He was discharged on this medication. Additionally, Nortriptyline was discontinued due to ACS. An additional rapid response was called on 3/11 due to possible right sided weakness and decreased responsiveness, however this could not be appreciated by the FMC team on exam. CT head and stat labs were obtained, all of which were unremarkable. Patient's mood was down due to recent medical diagnoses, procedures, and new long term placement and this was thought to contribute to presentation during the rapid response. Patient could not return to senior care facility due to the cholecystostomy drain. Psychiatry was consulted due to patient's complex psychiatric diagnoses and medical regimen. He was placed back on his prn Alprazolam, which did improve his overall anxiety.   Patient was evaluated on the day of discharge and appeared remarkably well. Pt was sitting up in the recliner eating his breakfast. He denied fevers, chills, abdominal pain, chest pain, shortness of breath, and endorses increased energy. He had no questions or concerns.