Age: 90.0
Sex: M
Vaccine: COVID19-2
Symptoms: Acute respiratory failure, Anticoagulant therapy, Anticoagulation drug level below therapeutic, Aortic dilatation, Aortic valve thickening
Clinical narrative: Discharge Provider: MD Primary Care Provider: MD Admission Date: 3/2/2023 Discharge Date: Mar 7, 2023  PRESENTING PROBLEM: Hypoxia [R09.02] Acute hypoxemic respiratory failure [J96.01] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: 91 y.o. male with hx of HTN, HLD, DM2, A flutter on coumadin, chronic LE edema w/o hx of heart failure who presented to the ER secondary to shortness of breath.  He resides at an assisted living facility. There has been an outbreak of COVID-19 infection among the residents the past week.  The day prior to presentation, he tested positive for COVID-19.  Since then, he had been feeling extremely weak and the day of diagnosis, he had a ground level fall without injury. This morning, he was noted by the staff to be extremely weak and became hypoxic with O2 sats in the mid 80s.  At that point, the facility decided to send him to the hospital for evaluation.  History of atrial flutter, chronically anticoagulated with Coumadin.  He is hard of hearing and ambulates using a walker.  No reported fever/chills, nausea/vomiting, chest or abdominal pains.   Upon arrival to the ER, the patient was hypoxic with O2 sats down to 88% but afebrile.  Lab workup showed stable electrolytes, complete blood count and renal function.  INR was subtherapeutic at 1.4.  COVID screen was positive.  Chest x-ray showed bilateral airspace disease consistent with infectious etiology/pneumonia and cardiomegaly noted. In the ER, he was started on Decadron. The patient was admitted to the hospital medicine service with acute hypoxic respiratory failure secondary to COVID-19 pneumonia.   Patient continued on PO decadron and started remdesivir. He required up to 2L supplemental O2 via NC, but was able to wean back to room air on 3/5 and remained stable since that time. Checked d-dimer and bilateral LE doppler US given LE edema and subtherapeutic warfarin. D-dimer not elevated (400->360->190) and elevated CRP was down trending (32.9->->10.6). LE doppler US negative for DVT (although difficult to visualize some calf pains due to edema). Patient was also noted to have mild cardiomegaly/pulmonary edema on initial CXR. No known history of heart failure, but notes worsening LE edema over the past 6 months. Last echo 11/2021 with LVEF 66%, normal diastolic function, diffuse thickening of the aortic valve w/o stenosis. NT-Pro BNP 1221 (wnl, no prior to compare). Repeat echo was obtained 3/4 and noted LVEF 55%, RA/RV severely dilated with moderately decreased RV function and mod to severe TR, no pericardial effusion. LE edema slowly improved with only leg elevation. Ordered Ted hose for compression.  Given mod-severe TR could consider further work up in the outpatient setting depending on goals of care.     Patient continued on home warfarin for his A flutter, but also started on Lovenox bridge as levels remained subtherapeutic. On day of DC INR was 1.7 and patient will be Dced on home warfarin dosing with INR check in 1-2 days.  Pt also became bradycardic after steroids started and required holding of his home Cardizem. EKG obtained 3/4 with junctional bradycardia and non-specific t wave changes. Decadron was discontinued 3/6 given improved respiratory status and worsening hyperglycemia and bradycardia. Patient's HR and glucose levels gradually improved.  Zio patch ordered on DC to monitor rate off of the cardizem to ensure rates reasonably controlled.  PT/OT evaluated and recommended return to home with assist.