Age: 80.0
Sex: F
Vaccine: COVID19
Symptoms: Peripheral swelling, Red blood cell sedimentation rate normal, Renal artery stenosis, Renal impairment, SARS-CoV-2 test positive
Clinical narrative: Hospitalized (1.27.22 - 2.3.22); COVID-19 positive (1.2.22 initially/PCR + on 1.27.22 as well); Fully vaccinated PLUS Booster-moderna x3 Discharge Summary  MD (Physician) ? ? General Medicine  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: PA Admission Date: 1/27/2022 Discharge Date: Feb 3, 2022   Active Hospital Problems   Diagnosis Date Noted POA ? Non-ST elevation MI (NSTEMI) (HCC) 01/28/2022 Yes ? Chest pain on breathing 01/28/2022 Yes ? Bilateral renal artery stenosis (HCC) 01/28/2022 Yes ? Atherosclerosis of native arteries of extremity with rest pain (HCC) 12/30/2021 Yes ? Hypertension 09/27/2021 Yes ? Polymyalgia (HCC) 09/27/2021 Yes ? Iron deficiency anemia 06/30/2021 Yes ? Chronic obstructive lung disease (HCC) 01/11/2021 Yes ? Lumbar radiculopathy 09/21/2020 Yes ? Restless legs 10/29/2019 Yes ? Hypercholesterolemia 01/01/2011 Yes  Discharge Disposition:  home health care  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: SOB (shortness of breath)  Chest pain, unspecified type  Acute anemia  HOSPITAL COURSE: Patient is an 80-year-old female who presented to the emergency room with substernal chest pain and pressure and stabbing chest pain from the front to the back.  Patient has a history of coronary artery disease, chronic obstructive pulmonary disease untreated, thoracic aortic aneurysm, right subclavian stenosis, bilateral renal artery stenosis with her flow limitation, and bilateral lower extremity femoral artery stenosis with recent stenting.  Patient was admitted troponins were moderately elevated she did have a Lexiscan which was negative patient has significant peripheral vascular disease as well as coronary artery disease.  Patient responded well to treating chronic obstructive pulmonary disease, she is to discharge home on long-acting beta agonist combination inhaled corticosteroid and long-acting anticholinergic agent and p.r.n. albuterol.  The patient is to follow up with pulmonary rehab in also with Cardiology.  Patient has a standing appointment with vascular surgery for her right lower extremity pain swelling.  Her right femoral artery stenosis was complicated by the need for fasciotomy and she will need to follow up with vascular surgery.  The day prior to discharge patient had been started on new medications, her Coreg was discontinued in favor of Lopressor per Cardiology patient had orthostasis.  Will re-evaluate and repeat orthostatic blood pressure measurements for 24 hours and patient stable discharge home.   Acute increase in creatinine, 1 -> 1.44 -> 1.2 Thin woman with little muscle mass so suspect her renal function is worse than creatinine would suggest Soft BPs, if accurate, with RAS so does this reflect delicate balance of perfusion? CT contrast was given 1/27/22 Nephrology consulted   Chest pain: Resolved     NSTEMI II Demand ischemia due to anemia Hgb on admit 6.4 -> 2 units PRBCs, now 8s Lexiscan negative for flow restricted ischemia   Anemia, acute on chronic     Baseline 8-9s Hx transfusions No melena or hematuria Haptoglobin WNL at 127 DAPT FeSO4 q MWF to assist absorption Outpatient f/u advised   HTN      Agree w/ Cardiology this may be renovascular given medical refractoriness and abdominal CTA showing significant bilateral renal artery stenosis Nephrology appreciated Amlodipine 5 HS Chlorthalidone 25 d on hold due to soft BPs and increasing creatinine; new Losartan 100 d on hold due to soft BPs and increasing creatinine Lopressor 12.5 BID   Bilateral RAS / PVD     ARB Vascular Surgery appreciated - discussed with patient and husband there are many aspects of her condition just being discovered   Subclavian stenosis, right, per ultrasound.   Likely reason for discrepancy in blood pressures between arms. Patient has bilateral lower extremity stenosis status post right femoral artery stenting and bilateral renal artery stenosis.   Right LE with compartment sx Fasciotomy Pulse intact. No pain or color chages >>ASA + Plavix + high dose statin  Less likely claudication given ABI 1/13/22 with greatly improved flow to right LE   Thoracic aortic aneurysm: Stable CT 4 cm in the ascending region and dilated up to 4.1 cm in the distal descending region, no intervention at this time. Risk benefits will need to be discussed with vascular surgery at the point where surgery may be needed.   Hypercarbia     COPD, chronic Hx tobacco use, quit >15 yr ago Duonebs and albuterol PRN Symbicort BID (script) Albuteral PRN (script)   RLS    Due to iron deficiency anemia +/- recent vascular work on her right leg Oxy had been given recently as pain ensues once RLS starts and with activity Requip trial underway   Insomnia  Trazodone 100 HS   Underweight, BMI 18 Weight loss  Said she has not changed her intake Coached her on consuming high-caloric foods   DVT ppx: Activity in use Diet: heart hlthy 2 gm sodium Full code   Dispo: Home w/ husband, possible 2/3/22 depending on how she is feeling Rx Symbicort and albuterol OP check of hgb and creatinine  H&P 1/27/22- CHIEF COMPLAINT Patient presents with ? PALPITATIONS    pt sts this started a few days ago, but seems to be getting worse. pt c/o chest tightness and sob when walking around.  1.  NSTEMI II lexiscan negative for flow restricted ischemia   Hgb on  Admit 6.4  Last was 8.5  Om 1/2. Last normal              13.8 on 11/11/2021. 12/30/2021.  Possible demand ischemi  Due to amemia, transfused 2 unit PRBC .  No ECG  Changes 2. Acute on chronic anemia Usually 8-9 range, no melena or hematuria  Was on DAP possible colonoscopy/EGD  Will consult  GI.  Haptoglobin is negative, hemoglobin stable after transfusion 3. Bilateral RAS On  ARB Vascular consiult reviewed discussed with patient and husband at bedside there are many aspects of her care that they are just discovering.  Explained that stenting bilateral renal artery stenosis at this point would be counterproductive to good health. 4. COPD past smoker quit > 15y ago chronic hypercarbia  tart  duonebs and albuterol  5. RLS Due to  irobn  Def anemia pendinf work up  6. HTN   Due to bilateral RAS  7. PVD recemt angioplasty  R SFA with compartment Sx, S/P fasciotiopmy. Pulse intact. No pain  Or color chages >>ASA, plavix, high dose statin   8. Thoracic aortic aneurysm  stable on CT at 4.0 cm in the ascending region and dilated up to 4.1 cm in the distal descending region, no intervention at this time  continue scanning CT scans for aneurysm.  Risk benefits will need to be discussed with vascular surgery at the point where surgery may be needed. 9. Right subclavian stenosis please see ultrasound in note.  This could be the reason for the discrepancy in blood pressures in the arms.  Patient has bilateral lower extremity stenosis status post right femoral artery stenting and bilateral renal artery stenosis.   Summary of Hospitalization: Patient is a 80-year-old female who presented to the emergency room with substernal chest pain and pressure and stabbing chest pain from the front to the back.  Patient has a history of coronary artery disease, chronic obstructive pulmonary disease untreated, thoracic aortic aneurysm, right subclavian stenosis, bilateral renal artery stenosis with her flow limitation, and bilateral lower extremity femoral artery stenosis with recent stenting.  Patient was admitted troponins were moderately elevated she did have a Lexiscan which was negative patient has significant peripheral vascular disease as well as coronary artery disease.  Patient responded well to treating chronic obstructive pulmonary disease, she is to discharge home on long-acting beta agonist combination inhaled corticosteroid and long-acting anticholinergic agent and p.r.n. albuterol.  The patient is to follow up with pulmonary rehab in also with Cardiology.  Patient has a standing appointment with vascular surgery for her right lower extremity pain swelling.  Her right femoral artery stenosis was complicated by the need for fasciotomy and she will need to follow up with vascular surgery.  The day prior to discharge patient had been started on new medications, her Coreg was discontinued in favor of Lopressor per Cardiology patient had orthostasis.  Will re-evaluate and repeat orthostatic blood pressure measurements for 24 hours and patient stable discharge home  Admission History and Physical  CHIEF COMPLAINT Chest pain   ASSESSMENT AND PLAN Chest pain Elevated troponin - patient with intermittent chest pain for last 3 days. Described as sharp substernal pain with radiation into back. Also some chest pressure. 3-4 episodes a day lasting about 30 minutes. Pain worse with laying and better when sitting up. Accompanying SOB with pain. - EKG showing sinus rhythm with ST abnormalities in lateral leads - CXR negative for acute process - CTA thorax negative for acute aortic pathology - trop 29 -> 51 - ESR, CRP WNL - cardiology consulted, appreciate recs              - lower suspicion for ACS at this time              - Now Echo pending - on nitro drip, cards to manage - EKG with any recurrent CP - monitor on tele   Hypertensive urgency Essential HTN - BP elevated to 234/74 in ED. Takes BP at home and notes SBP normally in 150s but occasionally will go into 200s.  - on nitro ggt per cards - continue home Norvasc, metoprolol, losartan  - will add PRN hydralazine if needed for goal SBP < 180   Acute on chonic anemia - patient denies any signs of bleeding including melena, BRBPR, hematuria, hemoptysis, abnormal bleeding or bruising. Has darker stools but notes its been that way since restarting iron supplement. Lower suspicion for active bleeding at this time and lower second hgb likely 2/2 lab error. - initial hgb 7.3 -> 6.5  - hgb was 8.0 on d/c 1/2 - 1 unit PRBC ordered by cards on admission - stool hemoccult pending - anemia labs pending - continue to monitor H&H   Severe PAD - s/p recent balloon angioplasty of R superficial femoral/popliteral and stenting of R superficial femoral complicated by compartment syndrome requiring 2 compartment fasciotomy and wound VAC. - noted chronic differing upper extremity BP. No dissection or acute abnormalities noted on CTA - RUE doppler pending - will continue Plavix with low suspicion for bleed but will hold if continued hgb drop - continue BB and stain - take BP on left arm only   COPD, stable - not currently on inhalers at home   Covid positive - initially tested 1/1/22 and has remained asymptomatic - does not need precautions   CKD stage 3 - Cr 1.15 Which is around baseline - continue to monitor    HDL - continue home statin   Thoracic aortic aneurysm - stable on CT at 4.0 cm in the ascending region and dilated up to 4.1 cm in the distal descending region   RLS - continue home Mirapex    PMR - noted   Diet:  Heart healthy VTE Prophylaxis: holding with acute anemia but would start lovenox if hgb remains stable Code status: Full Code   HISTORY OF PRESENT ILLNESS Patient is a 80 y.o. female with past medical history significant for severe PAD, PMR, IDA, RLS, HTN, HDL who presented to the ED with complaints of chest pain. Of note, patient with recent admission 12/30-1/2 after undergoing RLE angioplasty and stenting with post-op complication of compartment syndrome requiring right lower extremity posterior 2-compartment fasciotomies with VAC placement. She was d/c home in stable condition. Per patient she began experiences intermittent chest pain 3 days ago. Notes pain is in the area of her sternum with radiation into her back. Pain is described as a sharp stabbing sensation with some pressure as well. Pain is worse with laying flat and improves with sitting up. Episodes last around 30 minutes and improve on their own. Notes she has been having 3-4 episodes a day. Notes associated SOB with pain episodes. Does have some minor SOB on exertion and minor cough but notes that is chronic and at baseline. Admits to some intermittent light headedness and dizziness with position change. Denies any fevers, chills, abdominal pain, N/V, constipation, diarrhea, urinary symptoms. Notes her RLE has been doing well with minimal pain. Does still have some RLE swelling but has not had any difficulty ambulating. Patient denies any recent signs of bleeding including melena, BRBPR, hematuria, hemoptysis, abnormal bleeding or bruising. Has darker stools but notes its been that way since restarting iron supplement. Notes compliance with her home medications.   Upon arrival to the ED, patient was tachy with elevated BP. EKG was obtained showing sinus rhythm with ST changes in lateral leads. Blood work was obtained showing hgb 7.3, trop 29 -> 51, normal inflammatory markers. Covid PCR remains positive. CXR negative for acute process. CTA thorax negative for acute aortic pathology. Patient was initially admitted to cardiology service. Anemia studies were obtained which showed hgb 6.5 (though suspect lab error). With hypertensive urgency and anemia, cardiology had low suspicion for ACS and transferred patient to IM service for further evaluation and management.  REVIEW OF SYSTEMS Review of Systems  Constitutional: Negative for chills and fever.  HENT: Negative for congestion and sore throat.   Eyes: Negative for visual disturbance.  Respiratory: Positive for cough (chronic) and shortness of breath. Negative for wheezing.   Cardiovascular: Positive for chest pain and leg swelling (R leg).  Gastrointestinal: Negative for abdominal distention, abdominal pain, blood in stool, constipation, diarrhea, nausea and vomiting.  Genitourinary: Negative for difficulty urinating, dyspareunia and hematuria.  Musculoskeletal: Positive for back pain (upper back). Negative for gait problem and neck pain.  Skin: Negative for rash.       Post surgical incision on RLE  Neurological: Positive for dizziness and light-headedness. Negative for weakness, numbness and headaches.  Psychiatric/Behavioral: Negative for agitation and confusion.      OBJECTIVE BP (!) 192/82  | Pulse 103  | Temp 37.2 °C (Oral)  | Resp 16  | Ht 1.702 m  | Wt 52.2 kg  | SpO2 100%  | BMI 18.02 kg/m²  Physical Exam Constitutional:      General: She is not in acute distress.    Comments: Thin appearing female  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Tachycardia present.     Comments: Decreased pedal pulse in RLE. Unable to palpate pulse in RUE (chronic per patient) Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Tenderness (in area around L shoulder blade) present.     Right lower leg: Edema present.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Comments: Post-surgical wound on R shin without surrounding erythema or discharge.   Neurological:     Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.