Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anticoagulant therapy, Atrial fibrillation, Bradycardia, COVID-19
Clinical narrative: Patient is a 78 y.o. female patient of MD with history of ESRD, A. fib, hypothyroidism, COPD, CHF, CAD, CVA, diabetes 2. Presented to hospital with respiratory failure due to COVID and possible superimposed bacterial pneumonia. She was found to be bradycardic in the setting of supra-therapeutic digoxin level and betablocker both held with improvement in HR. She was treated with dexamethasone and antibiotics with improvement in her symptoms. She is weaned off O2 currently on RA with PT/ OT suggesting Home care at discharge.   Hospital course   Acute on chronic respiratory failure with hypoxia At baseline she uses 2 L of oxygen by nasal cannula only at night Presents with complaints of progressive cough and dyspnea for 2 weeks Requiring oxygen 3 L by nasal cannula in the ED Treating for pneumonia and COVID as below Continues to be on 3 L O2, wean as tolerated Aggressive pulmonary hygiene Added acapella, mucinex, tessalon 11/23-  on RA Doing better overall   Left sided chest pain Reproducible, less likely cardiac Seems musculoskeletal due to cough EKG slow A.fib Troponin  flat Lidocaine patch, flexeril and Tylenol monitor   Covid-19 Virus Infection Date of onset of symptoms: 10/31 Symptoms present on admission: cough, dyspnea Date of covid positive test: 11/11 Vaccination status: vaccinated Imaging: cxr 11/18 showed left lower lobe opacification Oxygen requirements on admission: 3 L Current oxygen requirements: 1L Medical therapy: steroid for 10 days Consultants following: na Anticipated special isolation end date: 11/20 Patient looks better and out of isolation  Possible bacterial pneumonia Chest x-ray in the ED showed densities in the left lower lobe Reports cough with sputum in the context of COVID Plan to complete treatment with Rocephin/azithromycin for 7/5 days sputum culture not collected Switched to oral antibiotic.   COPD She usually uses oxygen at home only at night  no evidence of exacerbation on arrival with no wheezing Continue home bronchodilators Albuterol as needed   ESRD Usually dialyzes with Dr. MWF with a left upper extremity aVF Last dialysis 11/18 Removed 3 L along with albumin support Nephrology following HD on 11/20 Next HD 11/22- looks euvolemic   Slow atrial fibrillation A. fib controlled rate on arrival Patient has had a watchman procedure but also continues to use Eliquis She is planned to undergo an ablation as an outpatient later this week but this has been on hold due to COVID Noted to have bradycardic episodes, digoxin level of 2.8 Digoxin discontinued, metoprolol on hold Patient is currently asymptomatic Seen by cardiology, atropine for heart rate less than 40 Continue Eliquis HR improved   Elevated troponin Troponin elevated but with a flat trend in the context of ESRD Denies chest pain No further work-up   Acute Thrombocytopenia POA Platelet count  improved 85 >>> 155  History of coronary artery disease Chronic HFrEF Documented history of coronary artery disease though there is no recent documentation of her coronary anatomy. She follows with Dr.  TTE 12/20 showed ejection fraction of 40% She had an ICD in the past which subsequently had to be removed due to infectious complication Seems compensated on arrival Continue home Entresto Ongoing dialysis for fluid management   Patient seen and examined on the day of discharge.  She seemed clinically stable to be discharged home with home care.  Outpatient follow-up plans as outlined