Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Oxygen saturation decreased, Pectus excavatum, Pleural effusion, Pleural thickening, Pneumonia
Clinical narrative: 76YM admit 2 weeks after 2nd COVID 19 vaccine dose with  # pulmonary embolism.  unclear if provoked or unprovoked. Admits to long car ride approximately 3 weeks ago.  Also admits to receiving second dose of covid vaccine 2 wks ago.  No family history of blood clots.  No family history of miscarriages he is not up-to-date with his colonoscopy or other cancer screenings.  He does admit to a about a 20 pound weight loss but no other malignancy symptoms with no change in his appetite.  He denies any urinary retention or dribbling, dysphagia, melena, change in stool color, bright red blood per rectum. PMH Coronary artery disease status post 2 stents placed about 10 years ago, uncontrolled diabetes mellitus type 2, hypertension who received his second covid vaccine 2 weeks ago. Presents to emergency department on 4/23/2021 with a chief complaint of acute dyspnea X 1 week.  Presented to health care center for further evaluation and was told that he had pneumonia. He was started on azithromycin which he took for 5 days with some improvement in his symptoms; however, he still continued to have some dyspnea which eventually caused him to present to the emergency department for further evaluation. In ED  patient was found to be tachycardic with a heart rate up to 124. He was also found to be tachypneic up to 42 breaths/min. Patient was found to have an SPO2 of 87% on room air.  Sodium was found to be 127.  proBNP was mildly elevated 2276. CTA chest noted to have noted to have pulmonary emboli most pronounced within the segmental branches of the right lower lobe, No evidence of right heart strain, Small to moderate right and small left pleural effusions, pulmonary fibrosis with honeycombing.  Patient was started on a heparin drip and transition to Eliquis prior to discharge.   Initial thought was possible CT-guided biopsy however after further discussion with multiple consultants will hold off biopsy until patient improves. Will repeat imaging in 1 to 2 months patient follows up with pulmonology and decided patient would benefit from biopsy at that time.  Recommend a more conservative approach with initial stabilization of PE on anticoagulation, optimization of CHF management, cardiac risk stratification, then follow up Chest CT in 2 months with reconsideration of biopsy at that time. Patient was found to have a decreased EF with LVEF less than 20% severely decreased.  Cardiology was consulted and recommended diuresis and patient was started on Lasix 40 mg IV twice daily.  His carvedilol was doubled to carvedilol 6.25 mg b.i.d.  Cardiology Recommended diuresing patient and optimizing LV dysfunction medications.  Patient's losartan was held secondary to his hypotension. Patient lost 4 kg prior to discharge.  His oxygen was weaned down to 1.5 L prior to discharge.  He will be sent home with oxygen as his oxygen did decrease down to 85% on room air. #Acute systolic CHF w/ EF < 20% #Uncontrolled DM w hyperglycemia, Hgb A1c 13.5% 4/23/21  - Started Levemir to 7Units BID changed from Levemir 25U BID.  #Hyponatremia - improved    #Unintentional weight loss -Patient states he is lost 20 pounds recently with no change in his appetite Discharged home