Age: 49.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Hypoosmolar state, Hypothyroidism, Inappropriate antidiuretic hormone secretion, Inflammation, Leukocytosis
Clinical narrative: presents with progressively worsening dyspnea on exertion for the last few weeks, much worse over the last one day.    Patient reports feeling fatigued, having cough, and feeling more short of breath for the last day, and has developed central chest pain which is pleuritic in the emergency department.  She reports that the chest pain is 4/10 in severity and does not radiate.  Her caregiver at bedside reports that the patient has had worsening dyspnea on exertion for the last 3 or so weeks.  Of note, she becomes dyspneic with limited exertion, such as going up a flight of stairs, at baseline.  She had a fever of 101.4 °F at home earlier today, but denies chills or diaphoresis.  He had 1 episode of nonbloody vomiting earlier today.  Denies nausea at this time.  She received her second dose of the Moderna COVID vaccine yesterday, 4 weeks after the first.   They note that approximately 5 years ago, she had a prolonged admission for which she was transferred to OHSU and was on ECMO for a time before making a nearly full recovery.  She has had the baseline dyspnea on exertion since that time.   Review of Systems  Constitutional: Positive for fever and malaise/fatigue. Negative for chills.  HENT: Negative for sore throat.   Eyes: Negative for blurred vision.  Respiratory: Positive for cough and shortness of breath. Negative for hemoptysis, sputum production and wheezing.   Cardiovascular: Positive for chest pain.  Gastrointestinal: Negative for abdominal pain, diarrhea and vomiting.  Genitourinary: Negative for dysuria and frequency.  Musculoskeletal: Negative for back pain.  Skin: Negative for rash.  Neurological: Positive for weakness. Negative for tingling, sensory change and focal weakness.  Endo/Heme/Allergies: Does not bruise/bleed easily.  Psychiatric/Behavioral: The patient is nervous/anxious.       Past Medical History: Past Medical History: Diagnosis Date ? Developmental delay, moderate since birth   Functional equivalent to 10-12 year old, no formal testing done otherwise.   ? DVT (deep venous thrombosis) (HCC) 1/2016   while on ECMO ? Personal history of ECMO 1/2016   - ARDS after unknown viral illness   Past Surgical History: Procedure Laterality Date ? LUNG BIOPSY Left 1995   Mass noted following an MVA, was benign ? MASS EXCISION Right 2006   Growth removed from right knee ? PROCEDURE N/A 1/20/2021   Procedure: LAPAROSCOPIC CHOLECYSTECTOMY; CHOLANGIOGRAMS;  Service: Procedures;  Laterality: N/A;  POSSIBLE COMMON BILE DUCT ? PROCEDURE N/A 1/20/2021   Procedure: RIGID ESOPHAGOGASTRODUODENOSCOPY;  Service: Procedures;  Laterality: N/A;   Medications administered in the ED: Medications doxycycline (VIBRAMYCIN) 100 mg in sodium chloride 0.9 % (NS) 100 mL IVPB (100 mg Intravenous New Bag 4/9/21 2235) ceftriaxone (ROCEPHIN) 1 g in 50 mL SNAP IVPB (0 g Intravenous Stopped 4/9/21 2234)  Physical Examination: GEN: Very pleasant female sitting up in bed in NAD. Slightly anxious appearing.  HENT: Moist mucous membranes. No posterior oropharyngeal erythema or exudates. NECK: Supple. No cervical or supraclavicular lymphadenopathy.  CARDIOVASCULAR: Tachycardic rate and regular rhythm. No murmurs, rubs, or gallops. No pain with palpation of chest wall.  PULM: Normal effort. No use of accessory muscles. Clear to auscultation bilaterally. No wheezes or crackles. ABD: Soft. Non tender. Non distended.  EXT: No lower extremity edema. SKIN: No suspicious lesions noted on the exposed skin.    EKG: 04/09/21  Rhythm: Sinus tachycardia  Rate: 111  Axis: normal  Intervals: normal   Concern for possible inferior infarct noted, but felt less consistent with true ST depression  Recent Imaging: Chest x-ray, 04/09/21:  FINDINGS: LUNGS: Slightly low lung volumes.  There is hazy reticulonodular interstitial opacity seen within the left mid and both lower lung zones suspicious for interstitial pulmonary edema. CARDIAC: Slightly worsened mild cardiomegaly. MEDIASTINUM: Normal. PLEURA: No pleural effusion or pneumothorax. LINES/TUBES: None. BONES: There is mild rightward convexity curvature of the thoracic spine along with minimal multilevel degenerative change. OTHER: Surgical clips overlie the left lung apex medially and the right upper abdominal quadrant.   IMPRESSION: 1. See above.   CT angiogram pulmonary:  FINDINGS:   Motion degrades image quality slightly.   No pulmonary arterial filling defects are identified.   Mild lower lobe predominant atelectasis and/or scarring. A single  small bulla is present in the left lower lobe of the lung. Lungs are  otherwise clear. Large airways are patent.   Small bilateral dependent pleural effusions which are new relative  to the comparison examination. No pneumothorax.   Heart is normal in size. Relatively low attenuation pericardial  effusion is present which is new relative to the comparison  examination. Pericardial fluid measures up to 1.7 cm in thickness. No  thoracic aortic aneurysm or dissection. No mediastinal mass or  lymphadenopathy.   Two small enhancing foci are present in the liver, larger 1.8 in  length which are similar to the comparison examination. Interval  cholecystectomy. Visualized upper abdominal contents are otherwise  without significant abnormality.   There has been partial resection of the left 5th rib. Osseous  structures are otherwise intact.    IMPRESSION:  1. No evidence of pulmonary embolism.  2. Pericardial effusion and small bilateral pleural effusions which  are new relative to comparison examination.  3. Two small enhancing liver lesions which are not further  characterized by this examination but are similar to comparison  examination. These could potentially represent hemangiomas.    Assessment / Plan   a 49 y.o. female with history of hypertension, developmental delay, DVT x1 not currently on anticoagulation, GERD, and anxiety who is being admitted for acute hypoxic respiratory failure, felt likely secondary to fluid overload from cardiomyopathy from pericarditis with associated pericardial effusion.    #Acute hypoxic respiratory failure  #Elevated Pro BNP #Cardiomegaly  #Dyspnea on exertion  #Pleuritic chest pain #Elevated D-Dimer  Acute. Hemodynamically stable. On room air at home, and requiring 3 L via NC here. Considerations include new onset CHF, PE, PNA, PTX, pericarditis, pericardial effusion.  Presentation most concerning for new onset CHF/cardiomyopathy from pericarditis with associated pericardial effusion, as demonstrated on CT angiogram.  She has significantly elevated CRP which further supports pericarditis, and onset of symptoms approximately 7 to 10 days after receiving her first COVID-19 vaccine dose 4 weeks ago, which may be associated.  Also possible viral or idiopathic.  Mildly elevated BNP and pleural effusions suggesting cardiomyopathy.  Patient had a fever to 101.4 °F earlier today, per caregiver at bedside, and has had shortness of breath and cough, and thus pulmonary infectious process strongly considered, though clinically I feel infection less likely. She has a chronic leukocytosis and WBC is 21 today.  She received ceftriaxone and doxycycline for pneumonia today in the ED, and may consider continuing these tomorrow. No evidence to suggest tamponade on bedside POCUS. - Admit to PCU with tele  - Echo in AM  - Ibuprofen 800 mg 3 times daily and colchicine 0.6 mg daily for treatment of pericarditis - Diuresis: 40 mg IV Lasix given at 0037 - Respiratory support as needed, wean as tolerated   - RTDP - Incentive spirometry  - Consider continuing antibiotics pending clinical status in AM    #Leukocytosis  Acute.  WBC 21.5 on admit, increased from 15.1 two and a half months ago, but that was at end of admission for cholecystitis.  Potentially due to inflammation, possibly infectious process.  See discussion above.  - Trend with CBC   #Hypertension  Chronic, presumed well controlled.   - Continue home hydrochlorothiazide and losartan     #Thrombocytosis Acute.  Suspect reactive thrombocytosis due to inflammation from pericarditis.  -Daily CBC while inpatient   #Elevated AST and ALT  Acute, mild. Most likely secondary to congestive hepatopathy.  Will trend. - AM CMP    #Hypoosmolar hyponatremia Acute,  mild.  Considerations include beer potomania, hypothyroidism, SIADH, low solute diet ("tea and toast"), increased free water intake, medication induced (SSRIs, thiazides). Suspect low solute diet.  SIADH from pulmonary pathology is also possible. - Repeat BMP   #Anxiety Chronic, presumed stable.   - Continue home sertraline     Ppx: Lovenox  Central Lines/IVs/Tubes/Drains: PIV  CODE: Full Dispo: PCU with tele    Active Hospital Problems   Diagnosis SNOMED CT(R) Date Noted ? Elevated brain natriuretic peptide (BNP) level HORMONE LEVEL - FINDING 04/09/2021 ? Cardiomegaly CARDIOMEGALY 04/09/2021 ? Leukocytosis LEUKOCYTOSIS 04/09/2021 ? Acute respiratory failure with hypoxia (HCC) ACUTE RESPIRATORY FAILURE 04/09/2021 ? Dyspnea on exertion DYSPNEA ON EXERTION 12/21/2015