Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Blood magnesium normal, Blood osmolarity normal, Blood potassium normal, Blood sodium normal, Blood urea increased
Clinical narrative: Date of Service Aug-08-2022 1641  Date of Admission Admit Date: Aug-06-2022  Date of Discharge Date of discharge Aug-08-2022  Allergies ACE Inhibitors - Not Specified  Chief Complaint Weakness  Procedure(s) Performed None  Lab Results Aug-08-2022 0535 Serology PROCALC  1.23 Aug-08-2022 0535 Hematology WBC  2.7RBC  3.20HGB  9.6HCT  28.7MCV  89.7MCH  30.0MCHC  33.4RDW  13.2RDWSD  43.8PLT  126MPV  12.1AUTONEU%  49.5AUTOLYM%  29.9AUTOMON%  12.5AUTOEOS%  7.0AUTOBAS%  0.7AUTONEU#  1.3AUTOLYM#  0.8AUTOMON#  0.3AUTOBAS#  0.0AUTOEOS#  0.2NRBC%  0.0NRBC  0.0ESR  64HGB/HCT  3.0IG#  0.01IG%  0.4 Aug-08-2022 0535 Chemistry GLUCOSE  198BUN  53CREAT  2.1MDRD GFR  30NA  136K  4.7CL  105CALCIUM  8.0ALK PHOS  121CO2  24.4AST  39ALT  29AST/ALT  1.3TL PROT  5.2ALBUMIN  2.5TBILI  0.2OSMO  291.9ANION GP  11.3BUN/CRE  25.2CRP  6.70MAGNESIU  2.1 Aug-07-2022 0515 Chemistry CRP  7.70 Aug-06-2022 1930 Chemistry TROPI-HS  108 Aug-06-2022 1340 Serology PROCALC  2.02 Aug-06-2022 1340 Chemistry CRP  4.20HGBA1C  7.6TROPI-HS  147 Aug-06-2022 1322 Coagulation D-DIMER  0.56 Aug-06-2022 1322 Chemistry LDH  227DBILI  0.1 Aug-06-2022 0934 Serology COVID  PosINFLUA  NegINFLUB  Neg Aug-06-2022 0934 Hematology WBC  5.4RBC  3.28HGB  9.8HCT  30.0MCV  91.5MCH  29.9MCHC  32.7RDW  13.3RDWSD  44.9PLT  132MPV  11.5AUTONEU%  75.2AUTOLYM%  10.9AUTOMON%  13.3AUTOEOS%  0.0AUTOBAS%  0.2AUTONEU#  4.1AUTOLYM#  0.6AUTOMON#  0.7AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.02IG%  0.4 Aug-06-2022 0934 Chemistry GLUCOSE  192BUN  37CREAT  2.2MDRD GFR  29NA  139K  4.4CL  107CALCIUM  7.3ALK PHOS  103CO2  19.4AST  34ALT  24AST/ALT  1.4TL PROT  4.8ALBUMIN  2.8TBILI  0.4OSMO  291.4ANION GP  17.0BUN/CRE  16.8LACTATE  0.80MAGNESIU  1.6PROBNP  15908TROPI-HS  131 Functional Status* No Functional Impairments  Mental Status* Normal Cognition  Social History tobacco use Smoker, Current Status Unknown, Smoking Cessation Not Applicable  alcohol use No Known Use  drug use No Known Use  marital status Married  Health Concerns Diabetes mellitus  Persistent atrial fibrillation  Peripheral vascular disease  Chronic renal insufficiency  History of coronary artery bypass grafting  Coronary arteriosclerosis  Sinus bradycardia  Acute COVID-19  Smoker, Current Status Unknown  Father Deceased @ unknown age Myocardial infarction @ 65  Mother Deceased Malignant neoplastic disease @ 86 Diabetes mellitus  Daughter Alive Diabetes mellitus  Vital Signs Aug-08-2022 0802 O2Sat 98 Aug-08-2022 0800 T 97.8 HR     45 RR 15 BP   149 / 59 O2Sat 98 Aug-08-2022 0417 T 97.8 HR     49 RR 17 BP       161  / 61 PHYSICAL EXAM PHYSICAL EXAM CONSTITUTIONAL: Patient is pleasant, appears comfortable, non-toxic, and in no acute distress.  Patient is sitting in wheelchair washing his hair.  CARDIOVASCULAR: Heart has regular rate and rhythm, no edema noted. RESPIRATORY: Patient is on room air. Lungs clear to auscultation throughout. Respiratory effort is non-labored, no use of accessory muscles noted. Patient is non-cyanotic appearing. GASTROINTESTINAL: Abdomen is soft, nontender, and nondistended. Bowel sounds normoactive. NEUROLOGICAL: Patient is alert and oriented to person, place, time, and situation. PSYCHIATRIC: Patient's is calm, cooperative, affect is appropriate.  Consultations Cardiology  Hospital Course Pt. is a 81-year-old male with a medical history of diastolic heart failure, atrial fibrillation, hypothyroidism, coronary arterial disease, sleep apnea and chronic kidney disease. He arrived at the emergency department with profound weakness, that had been worsening for 3 days and erythema and edema on the anterior aspect of the left lower limb in the setting of COVID-19. Patient was admitted to inpatient under internal medicine with the incidental finding of elevated troponins in the absence of chest pains along with profound bradycardia/junctional rhythm with prolonged QTc and an extensive cardiac history. On admission, patient was found to have hypomagnesemia which was treated with magnesium sulfate and resolved as well as hypocalcemia resolved without intervention. Dr was consulted and ordered cardiac echo and cardiac stress test to evaluate heart failure. Patient was treated with Lasix 40mg with resolution of lower limb edema. X-ray of left tib-fib and doppler ordered to rule out underlying pathology were unremarkable. Per echocardiogram, patient was found to have chronic heart failure with preserved ejection, grade I diastolic dysfunction with LV ventricular ejection fraction >60%. Patients home medications of amiodarone and zoloft were held due to QTc prolongation. Home Apixiban was held, heparin 5000 unit Q8h was started for DVT prophylaxis. A single transient instance of oxygen desaturation to 92% occurred during sleep on the first night inpatient, resolved with 2L of oxygen which was weaned off the next morning with no further intervention. Over the course of the stay troponin peaked at 148 and trended down. Amlodipine 2.5mg was started due to worsening hypertension.  Patient has remained asymptomatic for bradycardia for the duration of his stay. Patient was stable at time of discharge.  Condition at Discharge Stable  Discharge Medications ACETAMINOPHEN 650 MG ORALLY DAILY AT 1700 amLODIPine BESYLATE 2.5 MG ORALLY EVERY DAY BLOOD PRESSURE (ePrescribed on Aug-08-2022 1719) APIXABAN 2.5 MG ORALLY TWICE DAILY Arginaid Packet 1 PKT ORALLY ONCE A DAY Atorvastatin Calcium Tablet 80 MG 80 MG ORALLY DAILY AT BEDTIME B Complex Capsule 1 CAP ORALLY ONCE A DAY FERROUS SULFATE 650 MG ORALLY EVERY 48 HOURS Fiber Formula Capsule 1 CAP ORALLY ONCE A DAY finasteride 5 mg tab 5 MG ORALLY ONCE A DAY gabapentin 600 mg tab 600 MG ORALLY TWICE DAILY hydrALAZINE HCl Tablet 25 MG 25 MG ORALLY 3 TIMES A DAY HYDROcodone-Acetaminophen Tablet 5-325 MG Continue taking same as home Lasix Oral Tablet 20 MG Continue taking same as home Levemir U-100 Insulin 100 unit/mL soln 15 UNT SUBCUTANEOUS ONCE A DAY levothyroxine 125 mcg cap 125 MCG ORALLY ONCE A DAY MULTIVITAMIN M PLUS 1 TAB ORALLY ONCE A DAY NovoLOG Solution 100 UNIT/ML 10 UNT SUBCUTANEOUS BEFORE MEALS Plavix 75 mg tab 75 MG ORALLY ONCE A DAY Vitamin D3 Capsule 125 MCG (5000 UT) 125 MCG ORALLY ONCE A DAY Zoloft 25 mg tab 25 MG ORALLY ONCE A DAY Discharge Disposition Discharge to home  Plan Assessment: -Type II myocardial infarction, due to demand ischemia from COVID-19 and CKD, troponin improved from 147 to 108 -Sinus bradycardia, history of sick sinus syndrome -QTc prolongation, secondary to QTc prolonging medications - improved -Essential hypertension -Chronic heart failure with preserved ejection, grade I diastolic dysfunction with LV ventricular ejection fraction >60% per echocardiogram on 08/07/22, possible acute decompensation -Profound weakness, secondary to COVID19 infection - improved -COVID 19 infection, not in respiratory failure -Diarrhea, most likely secondary to COVID-19 infection - resolved -Thrombocytopenia, likely acute response to COVID -Non-anion gap metabolic acidosis, likely renal etiology, improved -Acute kidney injury on chronic kidney disease stage 3a, creatinine 2.1 and baseline 1.6 - Stable -Hypomagnesemia, Mg 1.6 on admission - Resolved -Hypocalcemia, corrected Ca 8.3 on admission - Resolved -Hx of cellulitis with chronic bilateral diabetic foot wounds, osteomyelitis of the left heel and amputation of right toes 1-2 -Paroxysmal atrial fibrillation with rapid ventricular response, currently sinus rhythm -Coronary artery disease with chronic angina and placement of multiple stents with history of open-heart surgery -Type 2 diabetes mellitus with neuropathy and retinopathy, poorly controlled on long-term insulin -Hyperlipidemia -Peripheral vascular disease -Chronic iron deficiency anemia, Hgb 9.8 on admission - Stable -Hypothyroidism, on levothyroxine -Chronic constipation -Depressive disorder, moderate, recurrent, on Zoloft  Plan: Patient will discharge to home. Will resume all home medications except for amlodipine due to bradycardia and QTc prolongation. Patient will be starting amlodipine 2.5mg daily for hypertension. Patient will be sent home on a holter monitor for 7 days, given to him before discharge. Further discussion of CKD should be had with primary care provider.  Primary Care Provider   Electronically signed on Aug-08-2022 1857