Age: 89.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Blood urea nitrogen/creatinine ratio, Bradycardia, Brain natriuretic peptide increased, COVID-19, COVID-19 pneumonia
Clinical narrative: :Pt is a 89 yr/o female who presents with shortness of breath for past two days. Pt has had a cough, sneezing/tearing from eyes, body aches, and fever. Pt took home covid swab and was positive. Pt oxygen levels have been dropping despite her 2 liters continuous. Pt has had covid vaccine. No HA, sore throat, CP, abdominal pain, V/D, dysuria, or rash. Pt does bruise easily due to being on Eliquis. Pt has had covid vaccine.  Review of Systems  Constitutional: Negative for chills and fever.  HENT: Positive for congestion and rhinorrhea. Negative for sore throat.   Eyes: Negative for discharge.  Respiratory: Positive for cough and shortness of breath.   Cardiovascular: Negative for chest pain.   Review of Systems  Gastrointestinal: Negative for diarrhea and vomiting.  Genitourinary: Negative for dysuria.  Musculoskeletal: Positive for myalgias.  Neurological: Negative for headaches.  Hematological: Does not bruise/bleed easily  1/12/22 TT Echo: Physician Conclusions Any valve disease noted in the report is non-rheumatic unless otherwise specifically noted. Summary:                 1. Normal biventricular chamber size and systolic function. LVEF 50 to 55%.                          2. The patient is status post bioprosthetic aortic valve (#26 Evolut pro plus) with normal function.Mean                          gradient 8 mmHg, dimensionless index 0.52.                          3. Moderate mitral annular calcification with mild to moderate mitral regurgitation.                          4. Moderate tricuspid valve regurgitation.                          5. RVSP estimated at 42 mmHg.                          6. Dilated IVC consistent with elevated right-sided filling pressures. Findings Left Ventricle:           The left ventricular chamber size, wall thickness, and systolic function are within normal limits. There are                           no regional wall motion abnormalities observed.                           Indeterminate diastolic filling pattern due to mitral annular calcification.                           The ejection fraction biplane was calculated at 51%. Left Atrium:              Moderately dilated left atrium. Right Ventricle:          The right ventricular chamber size and systolic function are within normal limits. Right Atrium:             The right atrial chamber size appears normal. Aortic Valve:             s/p TAVR with Evolut Pro plus 26 mm.                           The peak instantaneous gradient of the aortic valve is 16 mmHg. The mean gradient of the aortic valve is                           8. mmHg. The aortic valve area by VTI, is calculated at 1.5 cm2.There is normal function in from the                           bioprosthetic aortic valve.                           There is no evidence of aortic valve stenosis. There is no paravalvular regurgitation appreciated.                           Dimensionless index is 0.52.   Mitral Valve:             Moderate mitral annular calcification.There is mild to moderate mitral regurgitation.                           There is no evidence of mitral valve stenosis. Tricuspid Valve:          The tricuspid valve is normal in structure and function. There is Moderate tricuspid regurgitation.                           Right ventricular systolic pressure of 42 mmHg.    Pulmonic Valve:           The pulmonic valve is not adequately visualized but Doppler appears normal.                           Trivial pulmonic insufficiency. Pericardial:              There is no evidence of pericardial effusion. Aorta/Great Vessels: Aortic root dimension within normal limits.                      There is no dilatation of the ascending aorta.                      The IVC appears to be dilated.  CBC w/Diff   Collection Time: 01/12/22 12:32 PM Result Value Ref Range   White Blood Count 4.03 (L) 4.5 - 11.0 10*3/uL   Red Blood Count 3.96 (L) 4.0 - 5.2 10*6/uL   Hemoglobin 10.8 (L) 12.0 - 16.0 g/dL   Hematocrit 35.9 (L) 36.0 - 46.0 %   Mean Corpuscular Volume 90.7 80.0 - 100.0 fL   Mean Corpuscular Hemoglobin 27.3 26.0 - 34.0 pg   Mean Corpuscular HGB Conc 30.1 (L) 31.0 - 37.0 g/dL   Red Cell Distribution Width-CV 15.4 12.0 - 16.8 %   Platelet Count 143 140 - 440 10*3/uL   Mean Platelet Volume 11.0 8.4 - 12.4 fL   Diff Type Hospital CBC w/AutoDiff (arb'U)   Neutrophils % 65.4 45 - 80 %   Lymphocyte % 22.8 15 - 50 %   Monocyte % 10.2 0 - 15 %   Eosinophil% 0.2 0 - 7 %   BASO% 0.2 0 - 2 %   Immature Granulocyte% 1.2 (H) 0.0 - 1.0 %   Nucleated RBC % 0 0 /100(WBC)   Neutrophil Abs 2.63 2.0 - 8.8 10*3/uL   Lymphocyte-Absolute 0.92 0.7 - 5.5 10*3/uL   Monocyte Absolute 0.41 0.0 - 1.7 10*3/uL   EOS-Absolute 0.01 0.0 - 0.8 10*3/uL   Basophil Abs 0.01 0.0 - 0.2 10*3/uL   Immature Granulocyte Abs 0.05 0.00 - 0.10 10*3/uL Comprehensive Metabolic Panel(CMP)   Collection Time: 01/12/22 12:32 PM Result Value Ref Range   Sodium 141 136 - 145 mmol/L   Potassium 3.1 (L) 3.5 - 5.1 mmol/L   Chloride 101 98 - 107 mmol/L   Carbon Dioxide 28 22 - 29 mmol/L   Anion Gap 12 5 - 13 (arb'U)   Glucose 95 74 - 99 mg/dL   Blood Urea Nitrogen (BUN) 55 (H) 10 - 20 mg/dL   Creatinine-Blood 1.79 (H) 0.55 - 1.02 mg/dL   BUN/Creatinine Ratio 30.7 RATIO   Estimated GFR 27 (L) >60 /1.73 m2   Estimated GFR if (Privacy) 32 (L) >60 /1.73 m2   Total Protein 5.9 (L) 6.2 - 8.0 g/dL   Albumin 3.1 (L) 3.2 - 4.6 g/dL   Globulin 2.8 1.5 - 4.5 g/dL   Albumin/Globulin Ratio 1.1 1.1 - 2.5 RATI   Calcium 8.9 8.4 - 10.2 mg/dL   Total Bilirubin 0.4 0.2 - 1.2 mg/dL   AST/SGOT 55 (H) 5 - 34 U/L   ALT/SGPT 52 0 - 55 U/L   Alkaline Phosphatase 90 40 - 150 U/L B-Type Natriuretic Peptide   Collection Time: 01/12/22 12:32 PM Result Value Ref Range   B-Type Natriuretic Peptide 155.3 4 - 254 pg/mL Troponin   Collection Time: 01/12/22 12:32 PM Result Value Ref Range   Troponin 0.205 (HH) 0.000 - 0.034 ng/mL Partial Thromboplastin Time   Collection Time: 01/12/22 12:32 PM Result Value Ref Range   Partial Thromboplastin Time 33.0 25.1 - 36.5 s Protime-INR   Collection Time: 01/12/22 12:32 PM Result Value Ref Range   Prothrombin Time 13.6 (H) 10.3 - 13.3 s   INR 1.2 INR Lactic Acid   Collection Time: 01/12/22 12:33 PM Result Value Ref Range   Lactic Acid  1.5 0.7 - 2.0 mmol/L  1/12/22  XR Chest 1 Vw  CONCLUSION: No acute abnormality 1/17/22  Hospital Course: Patient presented to the ER with shortness of breath and weakness.  She was known covid +. She was found to have acute on chronic hypoxic respiratory failure and was admitted for further management. Issues addressed this admission are detailed below.     Acute hypoxic respiratory failure secondary to COVID-19 PNA  On remdesivir and dexamethasone.  Was increased to high flow on 1/13 and started on baricitinib but it was discontinued due to worsening leukopenia.  Pt now stable on 2 liters oxygen with exertion     Chronic diastolic heart failure cont torsemide      Afib  New diagnosis could be illness related and transient. Has been back in sinus.  Already on beta blocker and AC.  echo with preserved EF.  F/u with cardio outpt      Mild asymptomatic bradycardia  Pt noted to have dips in heart rate to 50s and occassionaly 40's. Happens at rest and is asymptomatic.  Recommend observatoin. If worsens may need to decrease beta blocker.       Leukopenia/tcp appears to be related to baricitinib, improving with discontinuation. Recommend repeat cbc when       Essential hypertension bp has been climbing on steroids.  At one point prior to admission was on losartan but family unsure why it was discontinued.  Recommend monitoring bp at home if persists may need further treatment.       Acquired hypothyroidism  Synthroid     H/o DVT on eliquis, repeat dopplers with no clot  1/26/22 PCP F/u:  89 yr/o female who presents here for hospital follow-up after admission from 1/12/2022-1/17/2022 with COVID-19 infection and shortness of breath.  Patient have respiratory discomfort before admission and was diagnosed with acute on chronic respiratory failure.     Acute hypoxic respiratory failure secondary to COVID-19 PNA  and has received remdesivir and dexamethasone.  She was treated with high flow oxygen.  She was started on baricitinib but it was discontinued due to worsening leukopenia.  But her symptoms improved.  She is currently not on oxygen when she came to the office.  She still gets short of breath easily. Chronic diastolic heart failure she is doing well with the beta-blocker bisoprolol and diuretic with torsemide.  No complaining of dizziness.  She does have some leg swelling. Complaining of neck pain.  She is sleeping with one pillow. She was also diagnosed with atrial fibrillation.  She is not a candidate for anticoagulation with bleeding.  She does not have any palpitation. Leukopenia/tcp appears to be related to baricitinib.I will obtain blood work again today.  Hypertension she is doing well on the current regimen. Complaining of burning in the mouth.  She does have poor taste. She was brought to the office by her son and history obtained from both patient and son. The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past family history, past medical history, past social history, past surgical history and problem list.