Age: 58.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Angiogram pulmonary abnormal, Atrial fibrillation, COVID-19, Chest pain
Clinical narrative: Date of Admission: 11/6/2023   Date of Discharge: 11/8/2023   Issues to be Addressed at Follow-up: COVID-19 infection Acute hypoxic respiratory failure Elevated troponin-likely demand myocardial ischemia   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   11/7/2023 12:30 PM HEPATITIS B VIRUS SURFACE ANTIGEN (HBSAG) In process --       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? ESRD ON HEMODIALYSIS         Schedule: MWF 3rd shift ( 1430-1830)  Hemodialysis access: PPC Nephrologist: Dr.   Renal Case Manager:           ? ATRIAL FIBRILLATION, PAROXYSMAL   ? CAD (CORONARY ARTERY DISEASE) WO ANGINA       Cardaic cath: 6/15/18 1- Heavily calcified and tortuous arteries.  2- LM intact and LAD with luminal irregularities. 3- There is mild disease of the proximal LCX and severe ostial disease of OM1 noted (medium caliber vessel).  4- There is a severe tandem lesion in the distal RCA noted.  5- The LV was not entered. Please note for the procedure 3000 units of heparin were administered. The initial plan was to attempt the procedure without heparin given his embolic events (please see details in my H+P). However, during the procedure patient developed some thrombus in his radial artery so we decided to proceed with heparin. He received approx 45 units/kg which is slightly below the standard dose of 50 units/kg.   11/2/11: Right Dominant  Left Main: Ok  LAD: Ok  LCX: 40% ostial OM2  RCA: 90% distal, calcified, extreme proximal tortuousity  Left Ventriculography: n/a  Iliac angio: 50% right external iliac stenosis. No disease on left.  PCI of RCA attempted using multiple large caliber guides. Eventually able to cross lesion with a wire, but regrettably there was insufficient guide support to advance a balloon beyond. I would be reticent to use rotational atherectomy given the extreme wire bias proximally.    ? HTN   ? COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)     Resolved Hospital Problems   Diagnosis Date Resolved ? ACUTE HYPOXEMIC RESPIRATORY FAILURE 11/08/2023 ? CHEST PAIN 11/08/2023     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: The patient is a 61 year old male with an extensive medical history including but not limited to ESRD on HD M, W, F thru a left IVC perm-a-cath (last exchanged 8/2022) with history of failed decreased donor kidney transplant at Facility in 9/2012, OSA on nasal CPAP, severe CAD who is not a candidate for revascularization (See Dr cardiology note 4/2022, cardiac cath 5/2018->heavily calcified and tortuous arteries with severe ostial disease of Om1 of circumflex and severe tandem lesion in the distal RCA noted), history of paroxysmal afib not on anticoagulation, HFmEF (EF 40-45% on echo 9/2022), history of pericardial effusion and cardiac tamponade back in 8/2019 s/p emergent pericardiocentesis in 8/13/2019, history of recurrent MSSA bacteremia from possible endocarditis with "mycotic aneurysm of the  right CFA/SFA junction s/p excision of the right CFA/SFA with reconstruction (cryovein) and sartorius flap 05/2018 complicated by anuerysms in the CFA and SFA s/p graft and aneurysm excision with reconstruction (cryovein) on 6/28/23" perperipheral vascular disease s/p right BKA and left AKA, and history of Bell's Palsy who was admitted on 11/7/2023 with shortness of breath and chest pain-found to have COVID 19 infection.   High sensitivity troponin 403-- >402   (72 on 10/6/2023).     EKG with no ST elevation, sinus rhythm with PVC noted.  Possible biphasic T wave in leads V2-V3.  QTc also elevated at 524.    CTA chest on 11/7 with no evidence of PE at the main and lobar artery levels.   Did show an enlarged 3.7 cm pulmonary artery suggestive of pulmonary arterial HTN.   There also was bilateral ground glass opacities present possibly from acute COVID infection.      Of note, has been vaccinated x 5 against COVID with Moderna MRNA last dose 1/6/2022.      COVID-19 infection Acute hypoxic respiratory failure Chest pain likely musculoskeletal   Patient who presented with episodes of dyspnea and persistent episodes of chest pain predominantly pleuritic in nature, who was evaluated emergency department with CT angiogram of the chest without any evidence of pulmonary embolism, subsequently noted to have bilateral groundglass opacities with COVID test positive, found to have saturations dropping down to 88% on room air, empirically started on Decadron 6 mg p.o. daily along with remdesivir.   Patient's respiratory symptoms substantially improved within 48 hours of stay in the hospital, received 3 doses of remdesivir, on the day of discharge patient remained on room air, expresses to have absence of any further symptoms, educated that further 24 hours daily may be appropriate for him to be observed in the hospital as he has been off the oxygen since this morning, reluctant to stay any further, would like to be discharged after receiving dialysis as planned this evening.   Patient's troponins are substantially improved, serial EKGs does not show any evidence of significant changes in the ST-T,  troponins have trended down, which was deemed likely in the context of demand myocardial ischemia,, in the absence of further episodes of chest pain with absence of further cough symptoms, deemed appropriate that patient does not need any further ischemic work-up at the present time.   Patient was noted to have COVID-positive test on 11/6/2023, recommended for isolation till 11/16/2023.   Paroxysmal atrial fibrillation Currently remains sinus during this hospital course, refused/declined in the past for anticoagulation.   COPD-not oxygen dependent Patient has been off the oxygen from 11/8/2023, saturations remained greater than 88%.  Continued on Spiriva, Wixela.   ESRD on hemodialysis Plan for hemodialysis on 11/8/2023, subsequently outpatient hemodialysis will be achieved.     primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  COVID-19 infection   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. NEPHROLOGY - INITIAL INPATIENT CONSULTATION. NEPHROLOGY - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code       Note Details  Author  (M.D.) File Time 11/9/2023  8:17 AM Author Type Physician Status Signed Last Editor  (M.D.) Specialty Hospital Medicine Hospital Acct #   Admit Date 11/6/2023  ED to Hosp-Admission (Discharged) on 11/6/2023  ED to Hosp-Admission (Discharged) on 11/6/2023   Detailed Report  Note shared with patient Hospital Problem List   COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)  COVID-19 DISEASE  CHEST PAIN Resolved  ACUTE HYPOXEMIC RESPIRATORY FAILURE Resolved  ESRD ON HEMODIALYSIS  ATRIAL FIBRILLATION, PAROXYSMAL  HTN  CAD (CORONARY ARTERY DISEASE) WO ANGINA Care Timeline  11/07   Admitted from ED (Observation) 0439 11/08   Discharged 2110  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 11/8/2023)