Age: 61.0
Sex: F
Vaccine: COVID19
Symptoms: Acute kidney injury, Anticoagulant therapy, Atrial fibrillation, Blood chloride decreased, Blood creatinine increased
Clinical narrative: Component Results: Component Your Value Standard Range Flag; Troponin T, 2 hr., 5th gen 1923 ng/L<=10 ng/L<=10 ng/L H; Consider acute myocardial injury 2H Delta 862 ng/L ng/Lng/L;2H Delta Interp Changing    Evaluate for acute myocardial injury; Troponin T, 6 hr., 5th gen; 2104 ng/L; <=10 ng/L<=10 ng/L H; Consider acute myocardial injury; 6H Delta SEE COMMENT ng/L ng/Lng/L; Test cancelled. Specimen not received within delta timeframe.; 6H Delta Interp SEE COMMENT; Test cancelled. Specimen not received within delta timeframe. General Information-Ordered by, M.D., Ph.D._____________________________________________________ Your Admission - 03/30/21Printer friendly page--New window will open-Admission Summary-Notes-Clinical Notes H&P by M.D., Ph.D. at 3/30/2021  3:55 AM-Status: Signed-CARD 3 Admission Note-SUBJECTIVE- CHIEF COMPLAINT= Chest pain. HISTORY OF PRESENT ILLNESS Patient is a 56 y.o. female who presented to the Emergency Department due to chest pain. She has experienced this pain each evening for the past 3 evenings, and states that it starts in her right arm then migrates through her shoulder and across to her chest. The pain can last for anywhere from 5 minutes to 4 hours. This has come on at rest, but in the setting increased personal life stressors as well as uncontrolled hypertension. She states that she is normally on hydrochlorothiazide for hypertension, but ran out of this medication about a week ago. When she checked her blood pressure at home it was in the 230s/120s, therefore she presented to the emergency department locally. Her medical comorbidities are notable for poorly controlled hypertension, mixed hyperlipidemia that is untreated, current tobacco use (1-2 packs per day for 40 years), and medically complicated obesity. In the emergency department  she was found to have mild polycythemia with hemoglobin of 15.2 and leukocytosis of 13.7. INR, D-dimer, and BMP were normal.  High sensitivity troponin T was found to be 770 ng/L. ECG showed normal sinus rhythm with T-wave inversion in aVL that was not present on 08/25/2004. Chest x-ray was largely unremarkable. Her chest pain resolved, but given the elevated troponin ECG changes she was treated for NSTEMI with heparin infusion, and loaded with aspirin and clopidogrel and directly admitted to the Hospital Cardiology service.  Upon arrival she remained free of chest pain but continued to have significant hypertension. I have reviewed and updated the following: Past Medical History, Family History, Social History, and Allergies. Current Outpatient Medications on File Prior to Encounter:  hydrochlorothiazide (HYDRODIURIL) 25 mg tablet, Take 1 tablet (25 mg total) by mouth daily., Past Week at Unknown time; Lorazepam (ATIVAN) 0.5 mg tablet, Take 0.5 mg by mouth daily as needed for anxiety., More than a month at Unknown time. REVIEW OF SYSTEMS Pertinent items are noted in HPI; all other review of systems was negative. OBJECTIVE  VITAL SIGNS Temperature: [36.8 °C-36.9 °C] 36.9 °C; Heart Rate:  [83-117] 83; Resp Rate:  [20-26] 22; Blood Pressure: (164-195)/(81-129) 164/106; SpO2:[92 %-97 %] 95 %;Weight:  [104 kg-106 kg] 104 kg; Pulse Rate:  [90-109] 94. PHYSICAL EXAM General: Alert, oriented, no acute distress; HEENT: Mucous membranes moist, JVP difficult to assess due to body habitus; CV: Regular rate and rhythm without murmur; Lungs: Clear to auscultation bilaterally; Abdomen: Obese, soft, nontender, nondistended, normoactive bowel sounds; Extremities: No peripheral edema appreciated; Neuro: No focal deficits appreciated. DIAGNOSTICS I have reviewed labs and imaging from the past 24 hours. ASSESSMENT / PLAN Patient is a 56 y.o. female who was directly admitted to the Cardiology Service from  Emergency Department due to NSTEMI and poorly controlled hypertension. She also has untreated mixed hyperlipidemia and is a current smoker. We will continue to trend troponins and treat NSTEMI was heparin infusion, aspirin, and clopidogrel. I will start a statin and initiate low-dose lisinopril and carvedilol for blood pressure control with plans to up titrate as tolerated. I will update a lipid panel in checked for diabetes. I will obtain a TTE in the morning and keep her NPO for probable coronary angiogram pending negative COVID swab. #1 Non-ST Elevation Myocardial Infarction; #2 Poorly controlled systemic hypertension; #3 Mixed hyperlipidemia, previously untreated; #4 Medically complicated obesity (BMI 38-trend troponin- loaded with aspirin and clopidogrel- Aspirin 81 mg daily- clopidogrel 75 mg daily- moderate intensity heparin infusion- rosuvastatin 20 mg daily- lisinopril 2.5 mg daily, up titrate as tolerated- carvedilol 6.25 mg twice daily, up titrate as tolerated- holding home hydrochlorothiazide in lieu of lisinopril and carvedilol- lipid panel  - hemoglobin A1c- TTE- NPO for probable angiogram (not-ordered)- cardiac rehab consult ordered;#5 Abuse Tobacco Smoking- nicotine patch- nicotine inhaler as needed- nicotine cessation consult; #6 Anxiety She is prescribed lorazepam 0.5 mg which she takes when she has a panic attack which only occurs a couple times per year.  For now we will just monitor. Diet: NPO; Tubes/lines: PIV; VTE prophylaxis: heparin infusion; Code status: Full Code; Disposition: anticipate discharge to home when clinically stable. Counseling was provided face-to-face at bedside regarding the plan of care as stated above. I personally spent over half of a total 70 minutes in counseling and coordination of care as documented above. M.B.B.S. at 3/30/2021 10:58 AM Status: Signed. SUBJECTIVE HISTORY OF PRESENT ILLNESS Patient is a very pleasant 56-year-old female who is owner of multiple nursing facilities who presented with chest pain and hypertensive emergency. She ran out of her hydrochlorothiazide last week, was fairly busy managing all her nursing homes with COVID pandemic and vaccination program. She was having intermittent chest pain, chest pressure radiating to the right arm. In this setting she checked her blood pressure, and it was noted to be 240 systolic over 140 diastolic. In this setting was sent to the ER and subsequently sent here. Initial troponin was 770. Subsequently, it went up to 1923. Delta was 862. ECG showed sinus rhythm with clear ST depression in the inferolateral leads. Patient currently is chest pain-free. She was initiated on carvedilol and restarted her home hydrochlorothiazide. Blood pressure is better. She had a good night's sleep. OBJECTIVE  PHYSICAL EXAMINATION; Vital Signs: Noted.; General: Alert and oriented x3. Cardiac: S1, S2 normal.; Lungs: Clear.; Abdomen: Soft.; Extremities: No edema of feet.; Vessels: Peripheral pulses well-felt.; DIAGNOSTICS Creatinine is 0.7.  Bicarb is 30. ASSESSMENT / PLAN Patient, is a 56-year-old female with obesity, hypertension, smoking, presented with hypertensive emergency. Blood pressure is better controlled now. She did have clear ST-T changes with troponin elevation, and we will treat it as NSTEMI at this point. Certainly, this can be demand ischemia in setting of hypertensive emergency, but she has multiple risk factors which would warrant coronary artery disease evaluation. We will plan for an angiogram today. We will get an echo today. Post that, we will reassess and see how things go. It appears that this was in setting of medication noncompliance. However, if this happens again, we may also look for other secondary causes of hypertension, especially with the fact that her bicarbonate was 30. All her questions were answered. DIAGNOSES: #1 Hypertensive emergency; #2 NSTEMI; #3 Obesity. M.B.B.S. DD: 03/30/2021 08:54:32 CT; DT: 03/30/2021 09:13:15 CT; Job ID:  914158020/mjb. Sedation Note by HCP at 3/30/2021 10:22 AM Status: Signed. INTERVAL HISTORY AND PHYSICAL PRE-PROCEDURE UPDATE H&P reviewed. The patient was examined and there are no significant changes to the H&P. PRE-SEDATION ASSESSMENT Consent Consents Obtained: written. The benefits, risks and alternatives to the procedure and the potential need for sedation or anesthesia as well as the names, roles, and responsibilities of healthcare team members performing significant interventional tasks were discussed with the patient and/or decision maker: yes. Indications / Reason for Visit. Procedure / Reason for Visit: coronary angiogram with possible intervention. Presedation Assessment. The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, family history, medical history, social history and problem list: Yes. Review of Symptoms pertinent ROS negative. Physical Exam Mallampati: II - soft palate, uvula, fauces visible. Assessment Plan ASA Physical Status: class 3 - patient with severe systemic disease Sedation Plan: moderate sedation. Patient seen, evaluated, and approved for sedation: yes. Cardiology Fellow 11053  Discharge Instr - Referrals / Follow-Ups by HCP at 3/30/2021 11:18 AM Status: Written Take a copy of this after visit summary to your appointment(s).---------------------------------------------------- Monday, April 5th, 2021:-- 12:30 p.m. -- Hospital follow-up with Dr. primary care provider, at Medical Center------------------------------  --------------------------- You may have outpatient appointments at Clinic that changed during your hospitalization.  Refer to your  Clinic Patient Visit Guide (PVG) for the most current schedule of appointments and detailed instructions of tests/procedures. Call, if you did not receive an PVG or need to CANCEL any Clinic appointment(s). H&P by HCP at 3/30/2021 12:33 PM; Status: Signed; CARDIOLOGY 3 H&P HISTORY OF PRESENT ILLNESS; Patient is a 56 yo F with history of hypertension, dyslipidemia, smoking history, and obesity who presents with chest pain, found to have NSTEMI. She owns and runs 4 assisted living facilities. In the past three days, she has had chest pain at rest following dinner, while sitting in the living room. It has lasted from minutes to hours and was relieved on its own. Yesterday she was prompted by her husband to present for medical attention. She has smoked 1-2 packs daily for the past 40 years. She is on hydrochlorothiazide 25mg daily for her blood pressure. Blood pressure was 171/129 here in the ED. Troponins rose from 770 to 1061 to 1923. Current Medications: [MAR Hold] acetaminophen tablet 1,000 mg (TYLENOL), Q6H PRN; acetaminophen tablet 1,000 mg (TYLENOL), TID PRN; [START ON 3/31/2021] aspirin chewable tablet 81 mg, Daily; [MAR Hold] aspirin DR tablet 81 mg, Daily; atropine injection 0.5 mg, Q5 Min PRN; bisacodyl suppository 10 mg (DULCOLAX), Daily PRN; [MAR Hold] calcium carbonate chewable tablet 400 mg of calcium (TUMS), Q2H PRN; carvedilol tablet 25 mg (COREG), BID with meals; [MAR Hold] Clopidogrel tablet 75 mg (PLAVIX), Daily; [START ON 3/31/2021] Clopidogrel tablet 75 mg (PLAVIX), Daily; docusate sodium capsule 100 mg (COLACE), BID PRN; fentanyl injection 25 mcg (SUBLIMAZE), Q2 Min PRN; fentanyl injection 25 mcg (SUBLIMAZE), Once PRN; flumazenil injection 0.2 mg (ROMAZICON), Once PRN; heparin (porcine) 1,000 unit/mL injection 3,200 Units, PRN **OR** heparin (porcine) 1,000 unit/mL injection 6,400 Units, PRN; heparin (porcine) 100 Units/mL in NaCl 0.45% 250 mL infusion, Continuous; [MAR Hold] lisinopril tablet 2.5 mg (PRINIVIL,ZESTRIL), Daily; Lorazepam injection 1 mg (ATIVAN), Once PRN; midazolam (PF) injection 0.25 mg (VERSED), Q2 Min PRN; midazolam (PF) injection 0.5 mg (VERSED), Once PRN; midazolam (PF) injection 0.5 mg (VERSED), Q2 Min PRN; midazolam (PF) injection 1 mg (VERSED), Q2 Min PRN; NaCl 0.9 % bolus 250 mL, Once; NaCl 0.9% infusion, Once PRN; naloxone injection 0.2 mg (NARCAN), Once PRN; naloxone injection 0.2 mg (NARCAN), PRN; MAR Hold] nicotine 10 mg inhaler 1 puff (NICOTROL), PRN [MAR Hold] nicotine 21 mg/24 hr. 1 patch (NICODERM CQ), Daily; ondansetron (PF) injection 4 mg (ZOFRAN), Once PRN;[MAR Hold] polyethylene glycol powder packet 1 packet (MIRALAX), Daily PRN; promethazine injection 6.25 mg (PHENERGAN), Q6H PRN; [MAR Hold] rosuvastatin tablet 20 mg (CRESTOR), Daily at bedtime; sodium chloride 0.9 % injection 10 mL, PRN; sodium chloride 0.9 % injection 3 mL, PRN; sodium chloride 0.9 % injection 3 mL, Q12H SCH. OBJECTIVE BP 143/83  | Pulse 71  | Temp 36.6 °C (Oral)  | Resp 21  | Ht 165.1 cm  | Wt 104 kg  | SpO2 94%  | BMI 38.19 kg/m². Intake/Output Summary (Last 24 hours) at 3/30/2021 1212. Last data filed at 3/30/2021 1130. Gross per 24 hour Intake 323.71 ml; Output 700 ml; Net-376.29 ml; GEN: Pleasant, no distress CV: Regular, no extra heart sounds, JVP is flat; PULM: Clear bilaterally; EXTR: No edema, strong R radial pulse ; ;EKG: NSR, nonspecific changes. ASSESSMENT / PLAN NSTEMI, s/p PCI to circumflex 3/30/21; Hypertension, uncontrolled; Nicotine dependence; Dyslipidemia; Obesity. She has an NSTEMI with significant elevation in her troponin. We will proceed with coronary angiography for this and anticipate PCI. We will intensify her antihypertensive regimen. Nicotine cessation is critical and we will consult our cessation specialists. We will refer her to cardiac rehab. DAPT for 1 year. Plan:1. Coronary angiography with intervention today; 2. High intensity statin, uptitrate carvedilol, keep lisinopril 2.5mg, restart hctz later this evening.; 3. Nicotine cessation referral. Cardiac rehab referral; 4. F/u TTE. Addendum: Angiography demonstrated her culprit lesion to be in the circumflex for which she received a 2.5 x 16 mm synergy stent. Mild disease elsewhere. She will require DAPT for one year. The patient was seen and discussed with the attending consultant, Dr. and PA. M.D. Cardiology fellow 3/30/2021  Consults by HCP at 3/30/2021  1:51 PM Status: Signed Consult Orders 1. Cardiac Rehabilitation consult (hospital) [2222776702510] ordered by M.D. at 03/30/21 1136; 2. Cardiac Rehabilitation consult (hospital) [2222776391034] ordered by M.D., Ph.D. at 03/30/21 0343 Cardiac Rehabilitation Referral. Reason for Visit:  Cardiac Health Clinic consultation for referral to cardiac rehabilitation. Liaison met with the patient/family to discuss cardiac rehabilitation referral. Patient/family was provided with progressive verbal and printed home-going exercise guidelines. Patient/family understands and agrees with the exercise guidelines.1. Participation in a Phase II cardiac rehabilitation program is recommended.  Patient was informed about what cardiac rehabilitation has to offer and why it is beneficial. The plan of care for the rehabilitation program consists of risk factor modification, monitored and supervised exercise and assistance in the recovery process with ongoing education and support.  Patient is interested in attending a cardiac rehabilitation program.; 2. Eligibility: MI and PCI; 3. Exceptions/exclusions: None;.4. Referral: Patient agreed with referral to a cardiac rehabilitation program. Please see discharge order and/or letter for program details. Clinic Health System Phone:; 5. Appropriate referral information will be sent to the receiving cardiac rehabilitation program as applicable. Patient provided verbal authorization to send relevant materials to the cardiac rehab program. Recommend that the patient check with insurance company to verify coverage of the cost of cardiac rehabilitation program visits. Discharge Summary by PA at 3/31/2021 10:20 AMStatus: Addendium CARDIOLOGY HOSPITAL DISCHARGE SUMMARY DATE OF ADMISSION: 3/30/2021 DATE OF DISCHARGE: 3/31/2021 Discharge Provider:  M.B.B.S. Discharge Provider Team: RST CARD 3  PRINCIPAL DIAGNOSIS Non-ST Elevation Myocardial Infarction. DISMISSAL DIAGNOSES #1 Non-ST Elevation Myocardial Infarction; #2 Poorly controlled systemic hypertension; #3 Mixed hyperlipidemia, previously untreated;#4 Medically complicated obesity (BMI 38); #5 Abuse Tobacco Smoking, Nicotine Dependence; #6 Anxiety. RECOMMENDATIONS FOR FOLLOW-UP APPOINTMENTS CBC and Basic metabolic panel; Cardiovascular risk factor modification; Cardiac rehabilitation participation (set up); Nicotine cessation; Blood pressure monitoring and management; Plavix for one year, aspirin lifelong; Assess right radial access site. *Statin Therapy Initiated: *A fasting lipid profile showed: Total Cholesterol 173 mg/dL, Triglycerides 218 mg/dL, HDL 39 mg/dL, LDL 90 mg/dL. *Baseline LDL is [ ] mg/dl. Please titrate to meet goal lipid levels.*Please recheck lipids and ALT/AST in 6 to 8 weeks.*Goal of statin therapy is a LDL less than 70 mg/dl or a 50% reduction in LDL. FOLLOW-UP APPOINTMENTS For appointment details refer to your Patient Appointment Guide. HOSPITAL COURSE  Admission Weight: 104 kg; Dismissal Weight: 103 kg; BMI: Body mass index is 37.82 kg/m².Patient is a 56 y.o. female who presented to the Emergency Department due to chest pain. She has experienced this pain each evening for the past 3 evenings, and states that it starts in her right arm then migrates through her shoulder and across to her chest. The pain can last for anywhere from 5 minutes to 4 hours. This has come on at rest, but in the setting increased personal life stressors as well as uncontrolled hypertension. She states that she is normally on hydrochlorothiazide for hypertension, but ran out of this medication about a week ago. When she checked her blood pressure at home it was in the 230s/120s, therefore she presented to the emergency department locally. Her medical comorbidities are notable for poorly controlled hypertension, mixed hyperlipidemia that is untreated, current tobacco use (1-2 packs per day for 40 years), and medically complicated obesity(BMI 38.19 kg/m2). Intravenous heparin was initiated for the heparin nomogram. She was Plavix loaded and received aspirin.  Carvedilol, lisinopril and Rosuvastatin were initiated. She proceeded to coronary angiogram with drug-eluting stent to the left distal circumflex artery. Transthoracic echocardiogram demonstrated ejection fraction 63%. Nicotine dependence was consulted and provided cessation information and prescriptions for nicotine replacement therapy.    TEST RESULTS PENDING AT DISCHARGE :Pending Labs; None; DISCHARGE DISPOSITION: Home or Self Care [1]; CONDITION ON DISCHARGE: Stable. DIET AT DISCHARGE: Cardiac diet consisting of low sodium (1500 mg to 2000 mg per day), low cholesterol, low fat. No alcohol, (or discuss with physician).PRIMARY PROVIDER Patient Care Team:D.O. as External Primary Care Physician (Family Medicine) Primary Care Providers: Pcp (General); No address on file Primary Care Provider Phone Number: None Primary Care Provider Fax Number: None MARGIN CODE Operative Note Report Case/Log ID: 1507626443 Case Time: 10:44 AM Procedure Information CORONARY ANGIOGRAPHY Laterality N/A; Left Heart Catheterization Laterality N/A; Percutaneous Coronary Angioplasty Laterality N/A; Stent Placement Laterality N/A. Surgeons Surgeon Role M.D. Primary M.D. First Assistant, M.D. First Assistant, Diagnosis. Pre-op diagnosis: Non-ST Elevation Myocardial Infarction , Morbid Obesity Body Mass Index >= 35 with Comorbid Condition. Post-op diagnosis: Non-ST Elevation Myocardial Infarction , Morbid Obesity Body Mass Index >= 35 with Comorbid Condition. Anesthesia Type Moderate sedation (rn). Surgeon Documentation. No notes of this type exist for this encounter. Specimens None. Implants Implant Name LRB; Site No. Used; Manufacturer Mfr No.; Serial No.; Status; Type STNT SYNERGY XD DE 2.50X16 - LOG1507626443 N/A; Coronary Scientific H7493941816250 Implanted Cardiac Stent; Drains None Estimated Blood Loss None. Worsening shortness of breath COVID-19 positive on 06/06, Sxs started on 06/01   HPI:  This is a 61 year old female who presents with complain of worsening Shortness of breath, COVID-19 positive  PMHx Kidney transplant for glomerulonephritis, 1998, 2nd transplant in 2009 on Cellcept and prednisone and recurrent UTIs since then and since then when she gets UTI, she starts Cipro or Keflex   HOCM myectomy 2009. Just saw yesterday.  Denied CP/ SOB/ orthopnea/ cough/ leg swelling/ syncope/ PND.  stated " no gradients across LVOT.  At acceptable risk for planned procedure. Afib in 2009, Legally blind, Gout, Hand amputation 2017 at work , Hip replacement Ventriculostomy - cyst removed 1999] Pt completed COVID vaccination series (Pfizer 2/25/21, 3/18/21) but has been on immunosuppression 2/2 renal tx. Her symptoms have been persistent since 6/1. She states that she has been having fever morning and evening, cough, fatigue. She states that over the past 1-2 days prior to presentation to the ED she has had hypoxia to 85-89% on home pulse ox and intermittent episodes of fever, pt reports worse dyspnea w/ ambulation. Pt called her nephrologist on 06/01 and recommended course of Amoxicillin w/out improved, given worsening and not improving sxs her nephrollogist recommended to presented to the ED,     On arrival to the ED she was initially tachypnic with ambulation to the bed, but has since improved. On initial exam she is not in any acute respiratory distress.  CXR showed finding of viral PNA, Creatinine 1.17 baseline < 1.0 Sodium 126    This is a 61 year old female who presents with complain of worsening Shortness of breath, COVID-19 positive  PMHx Kidney transplant for glomerulonephritis, 1998, 2nd transplant in 2009 on Cellcept and prednisone and recurrent UTIs since then and since then when she gets UTI, she starts Cipro or Keflex   HOCM myectomy 2009. Just saw Physician yesterday.  Denied CP/ SOB/ orthopnea/ cough/ leg swelling/ syncope/ PND.  Physician stated " no gradients across LVOT.  At acceptable risk for planned procedure. Afib in 2009, Legally blind, Gout, Hand amputation 2017 at work , Hip replacement Ventriculostomy - cyst removed 1999]  Worsening shortness of breath COVID-19 positive on 06/06, Sxs started on 06/01   On arrival to the ED she was initially tachypnic with ambulation to the bed, but has since improved. On initial exam she is not in any acute respiratory distress.  CXR showed finding of viral PNA, Creatinine 1.17 baseline < 1.0 Sodium 126        Active Problems:   Active respiratory failure dute to COVID-19 Hypoxia Symptomatic 6/1, tested positive for COVID infection 6/6. Currently sat 93-95% on RA; States she sats down to 85% at night. Short of breath on ambulation Xray findings suggestive of atypical viral/Covid 19 pneumonia.  Plan: - dexamethasone, remdesivir, mucinex - Oxygen NC to keep SpO2 >94% - IS q1h - ID consult appreciate recommendations  - Mucinex,Sch, robitussin PRN and albuterol PRN  - Incentive spirometry    Kidney replaced by transplant Aki Increased creatinine 1.77 baseline  Hyponatremia Hypochloremia  - Creatinine 1.17 from 0.95 possible d/t dehydration.  - Na 126, Cl 94 Plan: - Normal saline bolus - Hold cellcep - Continue tacrolimus - Prednisone hold, due dexamethasone for tx of COVID infection - Hold lasix, allopurinol, lisinopril - Continue valgancclovir - Avoid Nephrotoxic agent  - renally dose meds - Gentle IVF NS 75 ml/hr  - Usodium and Uosm    Hypertension  Hypertrophic obstructive cardiomyopathy (HOCM) (HCC) Atrial fibrillation (HCC) DVT prophylaxis - Normal sinus rhythm on EKG Plan: - Heparin  - Continue atorvastatin, ASA, coreg - Monitor for palpitations, dizziness, headache, SOB - Holding Lisinopril and Lasix in setting of Aki  - Continue Coreg    Gastritis - currently asymptomatic Plan: -  Protonix while on Steroids    Prediabetes - Hgb A1C 6.1 4/3 Plan: - Low carb diet   Legally blind - Patient moves about room without difficulty