Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Atrial fibrillation, Blood gases abnormal, Blood lactic acid normal, Blood pH decreased
Clinical narrative: Patient currently inpatient at (3) days admission.  The patient is a 84 y.o. female with a past medical history significant for chronic diastolic heart failure, atrial fibrillation, CVA, DVT, diabetes mellitus type 2, carotid artery disease s/p endarterectomy, essential hypertension and hyperlipidemia who presents today with a chief complaint of shortness of breath.   Patient was a limited historian at the time of exam.  She reports that she presented to the ER because ?her husband was worried about her.?  When questioned, she does admit to some mild shortness of breath and intermittent cough.  Patient also admits to some fatigue and generalized weakness.  She denies any other complaints at this time.  Specifically, she denies fevers, rigors, anorexia, nausea, vomiting, abdominal pain or diarrhea.  She denies chest pain, palpitations, diaphoresis, lightheadedness or dizziness.  Patient reports that her legs are always swollen at baseline, and do not seem much more swollen.  She states that she does not weigh herself daily.  Endorses good medication compliance with her Lasix 20 mg every other day.  Denies orthopnea or paroxysmal nocturnal dyspnea.  Patient reports that she has been vaccinated for COVID-19.   Upon arrival to Emergency Department, the patient was noted to be hypertensive at 187/72.  She was also hypoxic on room air requiring 2 L nasal cannula.  CMP was grossly unremarkable.  Complete blood count was significant for hemoglobin of 10.4.  Lactate was normal.  High sensitivity troponins were flat.  NT-BNP elevated at 4286. VBG revealing a pH of 7.47 with a normal pCO2.  COVID-19 PCR was positive.  Chest x-ray demonstrating cardiomegaly with pulmonary vascular congestion.  Additionally, hazy pulmonary opacities in the mid and lower lungs, right greater than left.  CT head without IV contrast was negative for acute intracranial hemorrhage.  Probable moderate chronic small-vessel ischemic disease was noted.  No evidence for acute large territorial infarction.  EKG demonstrating normal sinus rhythm with a normal QTC.  Patient received Lasix 40 mg IV as well as Decadron 10 mg IV in the ER.  Patient was then transferred to the hospital for admission as inpatient status in stable condition for further workup, monitoring and treatment. COVID-19 pneumonia              -- > Symptom onset: 11/26              -- > COVID-19 (+): 11/29              -- > Vaccination status: Vaccinated, 2 doses of Pfizer Stable on 2 L nasal cannula Chest x-ray: Hazy pulmonary opacities in the mid and lower lungs, right greater than left.   Plan: - Start remdesivir with loading dose now, followed by maintenance dosing - Start Decadron 6 mg IV daily for 10 days - DVT prophylaxis with Xarelto - Albuterol p.r.n. - Trend CMP daily for 7 days - Trend CRP and D-dimer daily for 3 days - Supportive measures   Acute on chronic diastolic heart failure exacerbation Perhaps exacerbated by uncontrolled essential hypertension verses cardiomyopathy related to COVID-19 pneumonia Chest x-ray:  Cardiomegaly with pulmonary vascular congestion. NT-BNP 4286 High sensitivity troponins flat Prior Echocardiogram (05/2021) at heart and vascular specialists showing LVEF 66% with mild right ventricular dilatation, moderate right atrial dilatation and moderate left atrial dilatation.  Moderate tricuspid regurgitation.  Moderate pulmonary hypertension. Diuresed with Lasix 40 mg IV in the ER Hold home Lasix 20 mg every other day Start diuresis with Lasix 40 mg IV 2 times a day Update echocardiogram 2 L fluid, 2 g sodium restriction Daily weights with I's and O's every 4 hours   Acute respiratory insufficiency with hypoxia Multifactorial in the setting of COVID pneumonia and acute on chronic diastolic heart failure exacerbation Stable on 2 L nasal cannula Chest x-ray:  Cardiomegaly with pulmonary vascular congestion.  Hazy pulmonary opacities in the mid and lower lungs, right greater than left. Management as outlined above Monitor continuous pulse oximetry, wean as able   Altered mental status  Suspect related to COVID-19 infection Alert, oriented x3, however "off" according to husband per review of ER note, unable to reach husband via telephone to discuss baseline mentation CT head without IV contrast: Negative for acute intracranial hemorrhage.  Probable moderate chronic small-vessel ischemic disease was noted.  No evidence for acute large territorial infarction. UA pending, follow  Closely monitor with neuro checks Q4 STAT CT head with any neurological changes    Accelerated hypertension Renal artery calcifications Continue lisinopril-hydrochlorothiazide and carvedilol Prior office visit in June, blood pressure 138/86, however SBP's 180-190 on admission Continue home antihypertensives lisinopril-hydrochlorothiazide and carvedilol Will add hydralazine 25 mg orally 3 times a day p.r.n. for SBP greater than 180 mmHg If difficulty with blood pressure control, consider renal artery ultrasound   Persistent atrial fibrillation on Xarelto Rates currently well controlled Continue carvedilol 2 times a day Continue Xarelto Monitor electrolytes and replace p.r.n.   History of TIA versus CVA Continue baby aspirin and statin   History of DVT Continue chronic anticoagulation with Xarelto   Non-insulin-dependent diabetes mellitus type 2 Updated hemoglobin A1c pending Hold Metformin  Will start low-dose Humalog, adjust as needed given administration of Decadron for COVID-19 PNA Goal blood sugar less than 180   Obesity  BMI 37   Plaquenil use? Unclear as to why patient is taking Plaquenil Patient unreliable historian and unable to reach husband overnight    Hyperlipidemia Carotid artery disease s/p endarterectomy Continue baby aspirin and rosuvastatin   CODE: Full DVT Prophylaxis:  Chronic anticoagulation with Xarelto DIET:  Heart healthy, 2 L fluid, 2 g sodium   The above assessment and plan was discussed with medical group attending and he/she agrees with the treatment plan.