Age: 44.0
Sex: M
Vaccine: COVID19
Symptoms: Pleural effusion, Pleuritic pain, Pulmonary embolism, Ultrasound scan abnormal
Clinical narrative: FINAL DIAGNOSIS:      o Acute pulmonary embolism and DVT   SECONDARY DIAGNOSIS: Principal Problem:   Pulmonary embolism and infarction (CMS/HCC) POA: Yes Active Problems:   Tobacco abuse POA: Yes   Opioid dependence (CMS/HCC) POA: Yes   Pulmonary embolism (CMS/HCC) POA: Unknown   DVT (deep venous thrombosis) (CMS/HCC) POA: Unknown   Chest pain POA: Unknown   Hemoptysis POA: Unknown Resolved Problems:   * No resolved hospital problems. *     PDMP Query Date: 03/24/21 PDMP Comments: 03/22/21 suboxone 8mg/2mg #14/14 days multiple fills ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   BRIEF HOSPITAL COURSE:   a 44 year old male with h/o  of anxiety, depression, substance use on Suboxone, history of alcohol abuse, admitted 3/24/2021 with pleuritic chest pain and shortness of breath.  Evaluation was positive for bilateral DVT and pulmonary embolism     Bilateral PE, infarction, bilateral DVTs -No obvious precipitating factors -patient underwent first COVID 19 vaccine injection, is actually due for second shot.  Unclear if this is contributed, recommended to hold on getting second dose and discuss this with PCP.  -Also follow-up with PCP for appropriate cancer screening -patient was treated with therapeutic subcutaneous Lovenox, remained hemodynamically stable and is feeling better today.  Upon discharge we'll prescribe Elocon is 10 mg b.i.d. for another 5 days followed by 5 mg b.i.d. maintenance dose.  He will be provided with coupon for 1 month supply, he was recommended to follow-up with PCP for further recommendations.  He will probably need anticoagulation for at least 6 months or longer depending on further course. -Echocardiogram showed ejection fraction 50-55%, Mild mitral valve prolapse no evidence of RV strain.      Hemoptysis  -Most likely was related to PE and infarction -resolved.   Pleuritic chest pain, h/o Afib -Most likely pain was secondary to PE, improved -Continue Cardizem as prior to admission -Stop aspirin since patient will be on anticoagulation therapy   History of opioid dependence, alcohol abuse Continue suboxone     Ongoing smoking smoking cessation was advised   Disposition: Routine Discharge Home   CONSULTS: Consults Ordered during this Encounter Procedures ? Ancillary Service Request - IV Team New IV Start (multiple sticks for labs) ? Ancillary Service Request - Social Services     PROCEDURES: Procedures Ordered during this Encounter Procedures ? Patient is currently on therapeutic anticoagulation (warfarin, Pradaxa, IV heparin, Rivaroxaban) - no reassessment     RADIOLOGY TESTS:  CT CTA Chest Final Result   1. Segmental and subsegmental pulmonary emboli throughout the right lung, most prominent in the right lower lobe. Segmental and subsegmental pulmonary artery the left pleural effusion. 2. Wedge-shaped opacities at both lung bases concerning for small pulmonary infarcts.  3. No findings of right heart strain or pulmonary hypertension.   Impression discussed with Dr of the ER at 20:44 on 03/24/2021 by  phone.    Electronically signed by:  MD 3/24/2021 8:46 PM   US Legs Bil Venous DVT Final Result   Bilateral posterior tibial vein thrombosis.   This critical result was called to the clinical team, including  by telephone, at 6:00 PM by the sonographer, according to internal Department documentation.   Electronically signed by: MD 3/24/2021 6:16 PM   XR Chest PA and Lateral Final Result Small bilateral pleural effusions. Streaky left basilar opacity may reflect atelectasis or infiltrate. Small right basilar opacity of uncertain significance. All opacities are new since 2016. No pneumothorax.  4 week follow-up is recommended. If the abnormalities have not resolved by then, chest CT is recommended.    Electronically signed by: MD 3/24/2021 5:36 PM       ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   PROPOSED MANAGEMENT PLAN:   Risk for readmission within 30 days: o  Low   Pending results:  Unresulted Labs      . . .   Comprehensive Metabolic Panel [124639904]     Collected: 03/24/21 1818     Updated: 03/24/21 1823     Specimen Source: Blood, Venous     Morphology [124639439]     Collected: 03/24/21 1700     Updated: 03/24/21 1715     Specimen Source: Blood, Venous     Comprehensive Metabolic Panel [124637329]     Collected: 03/24/21 1700     Updated: 03/24/21 1705     Specimen Source: Blood, Venous     Troponin, HS [124637342]     Collected: 03/24/21 1700     Updated: 03/24/21 1705     Specimen Source: Blood, Venous         Recommended Testing:  o Refer to Hospital Course   DISCHARGE MEDICATIONS:     Medication List   STOP taking these medications  aspirin 81 MG Chew     TAKE these medications    Dose Ordering Provider Morning Afternoon Evening Bedtime apixaban 5 MG Tabs Commonly known as: ELIQUIS Instructions: Take 2 Tabs (10 mg total) by mouth TWICE A DAY for 5 days, THEN 1 Tab (5 mg total) TWICE A DAY. Start taking on: March 26, 2021     Signed by:  MD                   buprenorphine-naloxone 8-2 MG Film Commonly known as: SUBOXONE Instructions: Dissolve 1 Film under the tongue DAILY for 14 days. Instructions: NADEAN: xe2109242   Dose: 1 Film   Signed by: MD                   diltiazem CR 240 MG Cp24 Commonly known as: DILACOR XR Instructions: Take 240 mg by mouth DAILY.    Dose: 240 mg                         Where to Get Your Medication apixaban 5 MG Tabs       High-risk Medication Changes:  o Refer to Hospital Course    PTA Medication Changes:  o Refer to Hospital Course