Age: 87.0
Sex: M
Vaccine: COVID19
Symptoms: Red blood cell nucleated morphology, Red cell distribution width normal, Respiratory rate increased, SARS-CoV-2 test positive, Troponin increased
Clinical narrative: Hospitalized (11.22.21 - 11.24.21 - readmitted for worsening COVID 11.27.21 - present.  COVID-19 positive (11.21.21); Fully vaccinated x2 moderna.  Pt in Butterworth hospital 11/22-11/24 - zeeland hospital 11/27 -present  11/24/21 - d/c summary: Discharge Provider: Medical Doctor Primary Care Provider: Medical Doctor Admission Date: 11/22/2021 Discharge Date: Nov 24, 2021   Active Hospital Problems   Diagnosis Date Noted POA ? Pneumonia due to COVID-19 virus 11/22/2021 Yes ? Acute coronary syndrome  11/22/2021 Unknown ? AF (paroxysmal atrial fibrillation)  02/14/2020 Yes ? Essential hypertension 06/02/2017 Yes ? CAD (coronary artery disease) 06/09/2015 Yes   Resolved Hospital Problems No resolved problems to display.   Pre-Existing Active Problems   Diagnosis Date Noted POA ? Chronic kidney disease, stage 3b  09/30/2021 Unknown ? Subclinical hypothyroidism 09/30/2021 Unknown ? E coli bacteremia 12/03/2020 Unknown ? Transaminitis 12/03/2020 Unknown ? Cardiac pacemaker in situ 11/30/2020 Unknown ? Benign essential tremor 11/11/2020 Unknown ? AVM (arteriovenous malformation) of duodenum, acquired 04/21/2020 Unknown ? Anemia due to blood loss, acute 04/15/2020 Unknown ? NSTEMI (non-ST elevated myocardial infarction)  02/13/2020 Unknown ? Elevated LFTs 01/14/2020 Unknown ? At risk for falls 01/03/2020 Unknown ? Colon polyps 01/03/2020 Unknown ? Diverticulosis 01/03/2020 Unknown ? Benign prostatic hyperplasia, unspecified whether lower urinary tract symptoms present 06/11/2018 Unknown ? Class 2 obesity due to excess calories in adult 03/28/2018 Unknown ? Mixed hyperlipidemia 06/02/2017 Unknown ? Elevated prostate specific antigen (PSA)- 01/16/2012 Unknown ? Peripheral neuropathy   Unknown ? GERD (gastroesophageal reflux disease)   Unknown ? Venous insufficiency   Unknown ? PVC (premature ventricular contraction)   Unknown     Discharge Disposition:  home or self care    Active Issues Requiring Follow-up:  PCP cardiology   DETAILS OF HOSPITAL STAY:   PRESENTING PROBLEM: Acute coronary syndrome    HOSPITAL COURSE: per HPI:  Patient is an 87 y.o. male with h/o CAD with chronic angina, HLD, HTN, PAF/Watchman, CKD, BPH, GERD and obesity, transferring directly from hospital ER where he presented on 11/21 with c/o several-day h/o worsening dyspnea, fatigue and generalized weakness.   He thinks he last was feeling at baseline about 10d ago, since then, he has noted progressively worsening fatigue, dyspnea, prod cough. He recently went deer hunting, which only involved minimal walking but otherwise just sitting in the blind for long hours. He returned from hunting, felt extremely fatigued and per son, he did not look good, who insisted that he go to ER. Typically, he is able to ambulate without much difficulty, but recently he is unable to ambulate even20ft without excessive dyspnea.  Angina is chronic, both exertional and non exertional. Its midline and radiates to left axilla. Relieved by rest and ntg. He gets it everyday, and overall, is about the same.  He has had diminished appetite resulting in diminished oral intake.  He reports associated productive cough with rattling sensation in his chest.  He denies fevers or sweats, but has had intermittent chills.  His chronic angina has not been substantially increased from baseline, and he denies notable increase in chronic peripheral edema.   In the ER, he was afebrile, normotensive, with normal HR, elevated RR but normal SpO2 on RA alone.  Initial labs are notable for critical troponin with negative delta (194 à 180 -- > 161), elevated proBNP, stable renal dysfunction, and positive COVID screen.  EKG shows NSR with LBBB, without significant change from prior studies.  CXR showed no acute process, and CTA thorax revealed no PE but identified bilateral pulmonary opacities c/w COVID-19 pneumonia.  Cardiology was contacted from the ER and, though they felt his troponinemia likely signified type 2 NSTEMI (related to demand ischemia), recommended low intensity IV heparin infusion.   Presently, he feels about he same as when he came in.    in-house:  patient admitted for NSTEMI; also has COVID-19 PNA. did not receive any treatment for COVID as he was on room air for the most part; only seemed to need oxygen at night. he did have fevers here, was advised to treat these at home with tylenol. cardiology saw him, rec'd medical management with increase in imdur and start of cozaar.   at the time of departure patient was in good spirits and had no objections to discharge. only complaint was a cough. all questions and concerns addressed, all meds and follow-ups reviewed. advised to talk about getting a sleep study with his PCP.     CONSULTS / RECOMMENDATION: cardiology   INPATIENT PROCEDURES: CTA thorax echocardiogram BLLE venous duplex U/S CXR     BP 104/58  | Pulse 60  | Temp 38 °C (Oral)  | Resp 20  | Ht 1.753 m  | Wt 112.1 kg  | SpO2 94%  | BMI 36.50 kg/m²    Physical Exam Vitals reviewed.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Extraocular Movements: Extraocular movements intact.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.     Comments: device noted Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Comments: left diminished (exam improved since admission) Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.     Comments: obese  Musculoskeletal:     Left lower leg: Left lower leg edema:       Comments: trace edema  Skin:    General: Skin is warm.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.   11/27/21 - H&P: CHIEF COMPLAINT: Pneumonia due to COVID-19 virus     Assessment/Plan    ASSESSMENT / PLAN: Chronic kidney disease, stage 3b Assessment & Plan Hold HCTZ and ARB, follow Cr and GFR.    Subclinical hypothyroidism Assessment & Plan Continue synthroid    Cardiac pacemaker in situ Assessment & Plan Placed 11.2020. paced rhythm on monitor.    Anemia Assessment & Plan Mild currently continue iron  hx of GI bleed with anticoagulants.  Watch H/H closely with Lovenox.    Elevated LFTs Assessment & Plan Monitor probably secondary to covid   At risk for falls Assessment & Plan Per fall risk protocol  PT/OT consult Case management for discharge planning may need SAR or Home Health     Essential hypertension Assessment & Plan Mild diastolic hypotension will holdt HCTZ pt had not started losartan yet so will hold    Mixed hyperlipidemia Assessment & Plan   Hold statin inpt    Peripheral neuropathy Assessment & Plan Continue gabapentin   GERD (gastroesophageal reflux disease) Assessment & Plan Hx GI bleed on blood thinners. Continue PPI   * Pneumonia due to COVID-19 virus Assessment & Plan Vaccination failure, was inpt downtown 11/22-24/21 with COVID and assumed ACS. Improved and discharged home. Worsened and saw pcp yesterday. Tried to get in for monoclonoal antibody. Was not able to get in before O2 dropped at home to 84-85% on RA.  O2, currently 2LNC Decadron,  remdesivir Monitor closely for decompensation.      50 minutes were spent on the unit/floor with the patient with over 50% spent counseling and coordination of care related to covid dx .       Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 87 y.o. male who presents today with general unwellness feeling Pt was admitted 11/21-24/21 to SH MHC with covid and presumed ACS. Pt cardiac work up was negative and pt was discharged home. Pt was seen by pcp yesterday for worsening general feeling of unwell ness. They tried to get monocolonal antibody infusion but didn't get. Today started feeling worse. More Dyspnea with exertion more fatigue. Had diarrhea and decreased appetite. Pt states had accident last night.      Patient Active Problem List Diagnosis ? GERD (gastroesophageal reflux disease) ? Venous insufficiency ? PVC (premature ventricular contraction) ? Peripheral neuropathy ? Elevated prostate specific antigen (PSA)- ? CAD (coronary artery disease) ? Mixed hyperlipidemia ? Essential hypertension ? Class 2 obesity due to excess calories in adult ? Benign prostatic hyperplasia, unspecified whether lower urinary tract symptoms present ? At risk for falls ? Colon polyps ? Diverticulosis ? Elevated LFTs ? History of non-ST elevation myocardial infarction (NSTEMI) ? AF (paroxysmal atrial fibrillation) ? Anemia ? AVM (arteriovenous malformation) of duodenum, acquired ? Benign essential tremor ? Cardiac pacemaker in situ ? Subclinical hypothyroidism ? Pneumonia due to COVID-19 virus ? Chronic kidney disease, stage 3b   Past medical, surgical, family and social history reviewed.    Medical History Past Medical History: Diagnosis Date ? Adenomatous polyp of colon 7/07 ? AF (paroxysmal atrial fibrillation)  2/14/2020 ? ASHD (arteriosclerotic heart disease)     CABG 5/1/15 ? Atypical chest pain   ? Benign prostatic hyperplasia, unspecified whether lower urinary tract symptoms present   ? Cholangitis 11/2020 ? Cholelithiasis 03/04/2020 ? Chronic kidney disease, stage 3b  9/30/2021 ? Class 2 obesity due to excess calories in adult 3/28/2018 ? Diverticulosis   ? Elevated LFTs   ? Elevated prostate specific antigen (PSA)- 1/16/2012 ? Essential hypertension 6/2/2017 ? GERD (gastroesophageal reflux disease)   ? HTN (hypertension), benign   ? Mixed hyperlipidemia 6/2/2017 ? NSTEMI (non-ST elevated myocardial infarction) (HCC) 02/13/2019 ? Peripheral neuropathy   ? PVC (premature ventricular contraction)   ? Symptomatic anemia 4/15/2020 ? Venous insufficiency      Past Surgical History Past Surgical History: Procedure Laterality Date ? ENDOSCOPY, COLON, DIAGNOSTIC   04/21/2020 ? ENDOSCOPY, UPPER GI   04/21/2020 ? HX ANGIOPLASTY   1986   circumflex ? HX APPENDECTOMY   1960 ? HX CARDIAC CATHETERIZATION   02/13/2020 ? HX CATARACT REMOVAL Bilateral 2021 ? HX COLONOSCOPY   6/12/07   Doctor , 100/5, CF 140 ? HX COLONOSCOPY   8/16/10   Doctor , 100/5, 1/5, 4:23, 5:47 withdrawl time, CF160, Recall 5 yrs ? HX COLONOSCOPY   10/19/15   Doctor , 75/4, 1/5, 6:12, 5:06 withdrawl time, CF180, No Recall  ? HX COLONOSCOPY   4/21/2020 ? HX CORONARY ARTERY BYPASS GRAFT   5/1/15 Murphy   x3, LIMA-LAD, SVG-OM, SVG-PDA ? HX ERCP   12/02/2020   With Doctor ? HX HEMORRHOID BANDING   6/12/07   see above, RPL and LL ? HX LAP CHOLECYSTECTOMY   12/2020 ? HX LEFT ATRIAL APPENDAGE EXCLUSION   08/2020 ? HX PACEMAKER PLACEMENT   12/2020    Social History     Socioeconomic History ? Marital status: Married     Spouse name: Not on file ? Number of children: Not on file ? Years of education: Not on file ? Highest education level: Not on file Occupational History ? Occupation: Insurance company     Comment: retd Tobacco Use ? Smoking status: Former Smoker     Packs/day: 2.00     Years: 30.00     Pack years: 60.00     Types: Cigarettes     Quit date: 1986     Years since quitting: 35.9 ? Smokeless tobacco: Never Used Vaping Use ? Vaping Use: Never used Substance and Sexual Activity ? Alcohol use: Yes     Comment: occasionally 2 cases of beer a year ? Drug use: Never ? Sexual activity: Not on file Other Topics Concern ? Military Service Not Asked ? Blood Transfusions Not Asked ? Caffeine Concern Not Asked ? Occupational Exposure Not Asked ? Hobby Hazards Not Asked ? Sleep Concern Not Asked ? Stress Concern Not Asked ? Weight Concern Not Asked ? Special Diet Not Asked ? Back Care Not Asked ? Exercise Not Asked ? Bike Helmet Not Asked ? Seat Belt Not Asked ? Self-Exams Not Asked Social History Narrative   Independent; retired.     He is primary caregiver for his wife, with whom he lives in a 2 story condo. She suffers from MG.    Younger son helps with care needs; older son helps with transportation currently.    Drive   Social Determinants of Health  Financial Resource Strain: Low Risk  ? Difficulty of Paying Living Expenses: Not hard at all Food Insecurity: No Food Insecurity ? Worried About Running Out of Food in the Last Year: Never true ? Ran Out of Food in the Last Year: Never true Transportation Needs: No Transportation Needs ? Lack of Transportation (Medical): No ? Lack of Transportation (Non-Medical): No Physical Activity: Not on file Stress: Not on file Social Connections: Unknown ? Frequency of Communication with Friends and Family: Not on file ? Frequency of Social Gatherings with Friends and Family: Not on file ? Attends Religious Services: Not on file ? Active Member of Clubs or Organizations: Not on file ? Attends Club or Organization Meetings: Not on file ? Marital Status: Married Housing Stability: Unknown ? Unable to Pay for Housing in the Last Year: No ? Number of Places Lived in the Last Year: Not on file ? Unstable Housing in the Last Year: No  Family History Family History Problem Relation Age of Onset ? Arteriosclerotic Heart Disease Brother         died 54 ? Scleroderma Sister         died 68 ? Coronary Artery Disease Father         died 66  Prescriptions Prior to Admission (Not in a hospital admission)   Allergies Allergen Reactions ? Anticoagulants Other     GI BLEED   Review of Systems Constitutional:  Positive for activity change, appetite change and fever. Negative for fatigue and unexpected weight change.  HENT: Negative for hearing loss, tinnitus, congestion, sore throat and hoarse voice.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough and sputum production. Negative for wheezing and shortness of breath.   Cardiovascular:  Negative for chest pain, palpitations, orthopnea, claudication and leg swelling.  Gastrointestinal:  Negative for heartburn, nausea, vomiting, abdominal pain, constipation, diarrhea and blood in stool.  Genitourinary:  Negative for difficulty urinating, urinary incontinence, dysuria, frequency, hematuria and urgency.  Musculoskeletal:  Negative for joint pain and muscle pain.  Neurological:  Negative for headaches, seizures, tremors, numbness/tingling and weakness.  Psychiatric/Behavioral:  Negative for suicidal ideas.  Skin:  Negative for itching, color change, new spots and changed spots.  Objective  OBJECTIVE: BP 134/54  | Pulse 63  | Temp 36.8 °C (Skin)  | Resp 16  | SpO2 94%    Physical Exam Constitutional:      Appearance: He is well-developed.  HENT:     Head: Normocephalic.     Right Ear: Tympanic membrane, ear canal and external ear normal.     Left Ear: Tympanic membrane, ear canal and external ear normal.     Nose: No septal deviation, mucosal edema or rhinorrhea.     Mouth/Throat:     Pharynx: Uvula midline.  Eyes:     General: Lids are normal.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Thyroid: No thyroid mass.     Vascular: No carotid bruit.     Trachea: Trachea normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses:          Carotid pulses are 2+ on the right side and 2+ on the left side.      Radial pulses are 2+ on the right side and 2+ on the left side.       Femoral pulses are 2+ on the right side and 2+ on the left side.      Dorsalis pedis pulses are 2+ on the right side and 2+ on the left side.       Posterior tibial pulses are 2+ on the right side and 2+ on the left side.     Heart sounds: S1 normal.   No systolic murmur is present.  No diastolic murmur is present.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Examination of the right-lower field reveals decreased breath sounds. Examination of the left-lower field reveals decreased breath sounds. Decreased breath sounds present.  Chest:  Breasts:     Right: No supraclavicular adenopathy.     Left: No supraclavicular adenopathy.    Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.     Hernia: No hernia is present.  Musculoskeletal:        General: Normal range of motion.  Lymphadenopathy:     Cervical: No cervical adenopathy.     Upper Body:     Right upper body: No supraclavicular adenopathy.     Left upper body: No supraclavicular adenopathy.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes more than 3 seconds.     Findings: No abrasion.      Neurological:     Mental Status: He is alert.     Cranial Nerves: No cranial nerve deficit.     Sensory: No sensory deficit.     Deep Tendon Reflexes: Reflexes are normal and symmetric.