Age: 69.0
Sex: M
Vaccine: COVID19-2
Symptoms: Abdominal distension, Anticoagulant therapy, Atrial flutter, COVID-19, Cardiac assistance device user
Clinical narrative: COVID+ - unknown date in October 2022 - Vaccination status - Pfizer x4 + pfizer bivalent BRIEF OVERVIEW: Discharge Provider:  MD Primary Care Provider:  DO Admission Date: 10/28/2022 Discharge Date: 11/15/2022 Presenting Problem: Cardiogenic shock (HCC)   Active Hospital Problems   Diagnosis Date Noted POA ? Cardiogenic shock (HCC),chronic, requiring palliative milrinone 10/28/2022 Yes ? Acute on chronic combined systolic and diastolic heart failure (HCC) 10/16/2017 Yes ? CAD (coronary artery disease)   Yes ? Atrial flutter, unspecified type  05/25/2022 Yes ? Cardiomyopathy, EF 10% (no device)  10/28/2022 Yes ? HIV (human immunodeficiency virus infection) (HCC) 12/20/2008 Yes ? Co-morbid condition 11/04/2022 Unknown ? Encounter for pre-transplant evaluation for heart transplant 11/04/2022 Unknown ? PEA (Pulseless electrical activity) (HCC) on presentation, resolved 10/28/2022 Unknown ? Type 2 diabetes mellitus without complication, without long-term current use of insulin (HCC) 06/10/2022 Yes ? Prostate cancer (HCC), s/p prostatectomy 2011    DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 69 year old male with PMH of chronic systolic and diastolic heart failure, ICM with variable EF over the years, CAD s/p 4v CABG 2016 with subsequent PCI 2017, CKD 3, hypertension, hyperlipidemia, HIV, hepatitis C, hx ischemic colitis, ileostomy, ascites, prostate cancer, OSA. Patient has followed with Cardiology for years since CAD/CABG in 2016. He was recently diagnosed with new atrial flutter RVR following recent COVID infection at a local ED: started on cardizem and no OAC. Patient declined cardioversion.    He felt poor for 3 weeks prior to admit with dyspnea, abdominal distention, and fatigue. He presented to HCF 10/16 and suffered PEA arrest with about 20-30 minutes of downtime. He was intubated 10/16-10/19. He was not hypoxic nor did he have significant electrolyte derangments. Echo 10/17 showed severely reduced LVEF of 18%, severe global hypokinesis,a dn RV dysfunction. He underwent L/RHC 10/24 that showed overall chronic, stable CAD compared to last cath in 2017, hemodynamic showed significantly elevated bilateral filling pressures and cardiogenic shock. He was diuresed with IV lasix but renal function worsened and he was transferred to a HCF 10/28 for management of cardiogenic shock.    On admit to the HCF, he was started on milrinone 0.2. He was diuresed more aggressively with lasix drip. Midodrine added for MAP goal >65. Eliquis was held and bridged with heparin gtt. He had ongoing atrial flutter RVR with variable block. He was loaded with digoxin which improved HR. He had TEE/DCCV 11/1 with successful cardioversion to NSR. RHC 11/1 showed RA 4, PAP 70/24/40, W 24, CI 2 on milrinone 0.2. Milrinone was increased to 0.3. Advanced therapies evaluation was triggered and patient was presented at selection. Patient was not an advanced therapies candidate due to BiV failure, concern for infections with HIV, recent bowel ischemia.   He was started on low dose Toprol XL for GDMT. He had recurrent atrial flutter on the afternoon of 11/9 with HR around 130 bpm. He was given increased Toprol XL and a bolus of Amiodarone. HCP was asked to see him again as he remained in AFL with rapid rates. Due to multiple medication interactions (with HIV meds, possible antifungal med) AAD options were limited. After thorough review HCP advised Amiodarone. A repeat CV was performed on 11/14 which was successful.    Patient fitted with Lifevest prior to discharge. Patient had home milrinone arranged at discharge.   On 11/15, patient remained in normal sinus rhythm and was medically stable for discharge to home with home health care, follow up appointment and labs in place. All of patient's questions were answered.     CONSULTS:  CTS Infectious disease Palliative care Electrophysiology