Age: 81.0
Sex: M
Vaccine: COVID19-2
Symptoms: Positive airway pressure therapy, Pulmonary hypertension, SARS-CoV-2 test positive, Sinus bradycardia, Syncope
Clinical narrative: patient is a 81 y.o. male w/ HTN, HLD who presented from outside hospital as direct admit on 7/28/2023 with NSTEMI and Covid w/ hypoxia.  Patient initially presented for syncopal episode, likely due to combination of dehydration and COVID-19.  At outside hospital, was found to have elevated troponins with positive and therefore transferred.  He was seen by cardiology, thought to be demand ischemia related to syncopal episode and COVID.  No concern for acute coronary syndrome.  Echo obtained which was unremarkable.  Recommends outpatient stress test.  Patient initially required O2 however was weaned to room air on time of discharge and overall otherwise minimal symptoms from COVID.  He was discharged .  He was discharged with Decadron.  We will follow-up with his outpatient cardiologist.  Additionally, patient found to have iron deficiency anemia.  Started on oral iron and recommending outpatient  endoscopic evaluation.         Assessment and Plan Syncope -No obvious cause. Possible contributors are mild dehydration, covid infection.  Low suspicion that this is a reflection of symptomatic bradycardia or other arrhythmia -Patient reports syncopal episode after driving to work.  No preceding symptoms -EKG with sinus bradycardia, first-degree AV block, similar to prior -Baseline heart rate seems to be around 5060.  He is on metoprolol -Monitor on telemetry, few PVCs.  V. tach and NSVT reported more likely to be artifact per cardiology -TTE findings below. Overall unremarkable -Encourage oral hydration NSTEMI -Suspect type II secondary to demand ischemia with syncopal episode/COVID.  Coronary calcifications noted on CTPA so possibly some atherosclerosis component -No noted history of CAD however patient does follow with a cardiologist Dr. at hospital for unknown reasons.  Denies prior ischemic work-up -Presented with syncopal episode.  Denied chest pain -Troponin 15>34>78>91>83 -EKG with sinus bradycardia, first-degree AV block.  No ischemic changes -TTE (8/28): LVEF 50+/- 5%, no wall motion abnormality, left atrial enlargement.  Pulmonary hypertension with RVSP 58 -Started on heparin at outlying ED -Continue ASA and statin -Cardiology following and recommending no further inpatient work-up.  Can follow-up with his outpatient cardiologist for Lexiscan Cardiolite stress test once out of COVID isolation   COVID Acute hypoxic respiratory failure, resolved -Symptom onset 7/26 with syncopal event, has mild cough and diarrhea.  Per patient family was having symptoms.  He is vaccinated -Tested positive at outlying ED and noted to be hypoxic -Started on dexamethasone 6 mg IV x 10 days (7/27) at outlier -Prn nebs and mucinex -He has been oxygenating well on room air for >24 without any respiratory symptoms other than a mild cough.  We will continue dexamethasone at discharge   HTN -Chronic, on metoprolol -BP stable -Continue    HLD -Chronic, on atorvastatin and fenofibrate -Continue lipid therapy at current dose.  May need to increase atorvastatin pending outpatient stress test.  Will defer to outpatient cardiologist   OSA Pulmonary hypertension -Noted pulmonary hypertension on echo with RVSP 58 -Compliant with CPAP, continue -On armodafinil, continue