Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: International normalised ratio increased, Magnetic resonance imaging head abnormal, Malaise, Metabolic function test, Pain
Clinical narrative: Assessment and Plan Patient is a 60 y.o. female patient of CNP with history of CVA, diabetes, hyperlipidemia, hypertension, seizures, submassive PE in August 2022 requiring tPA, DVT, COPD presenting with chief complaint of shortness of breath and cough.      Acute hypoxemic respiratory failure Oxygen saturation 87% on room air here. Etiology includes acute on chronic PE, pulmonary hypertension, COVID 19, COPD. Resolved.  INH now   Acute on chronic pulmonary embolism Right lower extremity DVT Patient with history of submassive or intermediate high risk PE 8/26/2022.  She received half dose tPA. She was on Coumadin this was switched to Eliquis last month by her primary care provider as per patient. CTPA study today: Acute on chronic pulmonary emboli in the bilateral lower lobe pulmonary arteries and right middle lobe pulmonary artery.  Pulmonary arterial hypertension.  Mild peribronchial thickening in the right lower lobe suggestive of bronchitis. She has been initiated on IV heparin gtt., continue. Consulted hematology with respect to decision on further anticoagulation with Eliquis versus Coumadin, input appreciated Discussed with patient, she was apparently taking Eliquis only once a day. There is also a concern with her carbamazepine interaction with Eliquis thereby decreasing the efficacy. Continue warfarin, pharmacy consulted to dose. Continue heparin for bridging, and adjust infusion rate. Due to concerns with compliance, patient will need to remain hospitalized until INR is therapeutic. INR is now 2.4.  Warfarin will be decreased to 5 mg daily.  She will be discharged home with follow-up at the Coumadin clinic. Compliance has been emphasized.   Covid-19 Virus Infection Date of onset of symptoms: 11/26 Symptoms present on admission: Yes, cough, shortness of breath, fatigue, body pains. Date of covid positive test: 11/27 Vaccination status: vaccinated Imaging: CTPA Oxygen requirements on admission: Yes, 2 to 3 L NC Current oxygen requirements: 2 to 3 L NC Medical therapy: steroids and remdesivir Consultants following: ID Anticipated special isolation end date: 12/05   AKI  Baseline creatinine 1-1.1 Patient received contrast on 11/27 Creatinine slightly bumped, now back to baseline Monitor daily BMP   Chronic CHF with preserved EF Does not appear volume overloaded on exam. Resume oral Lasix at discharge   Elevated troponin Patient reports that she had chest pain earlier which was worse with coughing.  Chest pain resolved now. EKG shows sinus rhythm with heart rate 98/min. Troponin elevation likely secondary to hypoxemic stress in the setting of PE. Trended troponins, trended down.    CVA MRI brain September 2022 showed remote left hemispheric infarct. On statin.  Not on antiplatelet agent.   Seizures Continue carbamazepine, Topamax as per home regimen.   Type 2 diabetes A1c hemoglobin 8/26 5.6. Resume Farxiga after discharge.   GERD Continue PPI.   Hypothyroidism Continue levothyroxine. TSH 09/18/2022 0.03.   Hyperlipidemia Continue statin.   Hypertension On lisinopril 10 mg daily which is her home dose. Continue. Chronic pain Continue gabapentin, Norco.   COPD Does not appear to be in exacerbation. Initiate Symbicort, Spiriva with as needed albuterol.