Date of Admission  01/12/2022   Date of Discharge  01/13/2022   Reason for Hospitalization   Afib with RVR, chest pain, COVID +  Hospital Course   Patient is a 63 yo female presenting to the ED with chest pain, found to be in Afib RVR. Recently diagnosed with COVID on 01/05. PMH: Atrial fibrillation (not on anticoagulation due to hx of bleeding), Hep C Cirrhosis complicated by ascites and varices, hx of variceal bleeding years ago (on Nadolol), hepatic encephalopathy, thrombocytopenia/pancytopenia (seen by heme/onc), subarachnoid hemorrhage (traumatic, while on anticoagulation, 2020), GERD, DM2 (currently not on meds), COPD (baseline 3 L), HTN, HFpEF, PAD, s/p sleeve gastrectomy (2020), CAD (CT coronary showed significant disease of the LAD and RCA with high calcium score), depression, anxiety, fibromyalgia.   Patient tested COVID-positive on 5 January, states that she was prescribed prednisone for 5 days and doxycycline for 7 days.  In the morning of admission she started having sudden onset substernal chest pain radiating to her throat/left-sided neck and her throat felt tight, she thought the chest pain was due to heartburn, however it kept getting worse so she decided to come to the ED. Pain started while she was watching TV, was burning in nature, constant. In the ED she still endorsed 6/10 chest pain, which improved after she converted to sinus rhythm while on Amiodarone gtt. Normal myocardial perfusion scan on 12/3/2021.   Upon presentation in the ED HR 150s-160s. EKG with Afib RVR and moderate ST depressions. Initial trop negative with minimal delta.  Received IV metoprolol pushes without resolution of RVR and with drop in BP. Started on Amio gtt and converted to sinus with improved chest pain and SOB. Labs in the ED notable for thrombocytopenia 40, neutropenia (mild, ANC 1300), normal hemoglobin, low Mg. Repeat EKG after conversion confirms sinus rhythm, ST/T changes not apparent. CTPE without PE, with findings of severe calcifications of the mitral valve. Scattered bilateral ground-glass and consolidative opacities consistent with patient's history of COVID 19. Bilateral interstitial opacities, suggestive of a superimposed mild interstitial pulmonary edema.   Amiodarone gtt discontinued, home Nadolol dose increased to 80 mg daily. Echo obtained with EF 60-65%. Posterior mitral leaflet calcified, no stenosis. Moderate LVH, severe LA dilation. Patient had further drop in ANC (570) and Platelets (29). No active bleeding. Touched base with heme/onc, no further work up at this time, ok to discharge. Close PCP f/u with labs. Peripheral smear pathology review ordered and pending. Patient instructed to avoid taking Aspirin. Instructed to come to the ED if any bleeding, fever, chills, worsening SOB.  Discharge Diagnoses      1. Cardiomyopathy    Orders:   diazePAM, 5 mg = 1 Tablet(s), form: Tablet, Oral, Daily, first dose 01/13/22 9:00:00, Physician Stop  dicyclomine, 10 mg = 1 capsule(s), form: Capsule, Oral, qid, first dose 01/12/22 17:00:00   fexofenadine, 180 mg = 1 Tablet(s), form: Tablet, Oral, Daily, PRN for Allergy Symptoms, first dose 01/12/22 16:00:00   nadolol, 80 mg = 4 Tablet(s), Oral, Daily, # 120 Tablet(s), Refill(s) 0, Pharmacy: (privacy)  nitroglycerin, 0.4 mg = 1 Tablet(s), form: Tablet Sublingual, Sublingual, q5min, PRN for Chest Pain, first dose 01/12/22 17:01:00   spironolactone, 50 mg = 2 Tablet(s), form: Tablet, Oral, Daily, first dose 01/13/22 9:00:00   CBC with Auto Differential  Change Accommodation  Culture Blood  Culture Blood  Follow Up Appt External Clinic or Provider  Follow Up Appt Medicine Cardiology  Heart Healthy (4gm NA, low fat)  Hemoglobin A1C  MRSA Screen by PCR  SCDs to bilateral LE's  Transition of Care - External  Vital Signs  Other Diagnoses   Ongoing  (HFpEF) heart failure with preserved ejection fraction  Abdominal pain  Anxiety  Cirrhosis  Degeneration of lumbar or lumbosacral intervertebral disc  Depression  Diabetes mellitus type II  Dysphagia  ESOPHAGEAL REFLUX  Esophageal varices  fi bromyalgia  H/O hernia repair  Hepatitis C infection  HTN  Irritable bowel  Kidney stone  Liver cirrhosis secondary to NASH  LUQ abdominal pain  Memory loss  Nephrolithiasis  Nocturnal hypoxia  Osteoporosis  Pancytopenia  Peripheral artery disease  Port-site hernia  S/P laparoscopic sleeve gastrectomy  Smoking  Urge urinary incontinence  Venous insufficiency  Historical  Colon cancer screening  Colonoscopy  COPD - Chronic obstructive pulmonary disease  Direct laryngoscopy with biopsy  Gravida 0  H/O: hysterectomy  HEADACHE  Health care maintenance  Hep C  Hx drug use  Morbid obesity with BMI of 40.0-44.9, adult  OCCLUSION AND STENOSIS OF CAROTID ARTERY, WITHOUT MENTION OF CEREBRAL INFARCTION  OTHER DYSPNEA AND RESPIRATORY ABNORMALITY  OTHER FACIAL BONES CLOSED FRACTURE  Pancreatitis  S/P revision of total knee  Subarachnoid hemorrhage  Tubular adenoma  tubular adenoma and hyperplastic polyp  Operations and Procedures   none  Consultants  Medicine Cardiology   Pending Labs  Blood Culture (Preliminary, InProcess, ordered 01/12/2022, 16:15)   Blood Culture (Preliminary, InProcess, ordered 01/12/2022, 16:15)   Discharge Disposition  home  Medications  New, Changed, or Refilled Medications  ARIPiprazole (ARIPiprazole 5 mg) 5 mg, 1 Tablet(s), Oral, bid, for 90 day(s), 180 Tablet(s), 3 Refill(s)    cholecalciferol (Vitamin D3 50 mcg (2000 intl units)) 50 mcg, 1 capsule(s), Oral, Daily, 90 capsule(s), 3 Refill(s)    famotidine (famotidine 40 mg) 40 mg, 1 Tablet(s), Oral, Daily, for 30 day(s), 30 Tablet(s), 0 Refill(s)    ferrous sulfate (ferrous sulfate 325 mg (65 mg elemental iron)) 325 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 3 Refill(s)    lisinopril (lisinopril 5 mg) 5 mg, 1 Tablet(s), Oral, Daily, 90 Tablet(s), 3 Refill(s)    magnesium hydroxide (Milk of Magnesia 8% oral suspension) 1.2 g, 15 mL, Oral, At Bedtime, PRN: as needed for constipation, 360 mL, 0 Refill(s)    nadolol (nadolol 20 mg) 80 mg, 4 Tablet(s), Oral, Daily, 120 Tablet(s), 0 Refill(s)      Medications to be Continued  DULoxetine (DULoxetine 60 mg oral delayed release capsule) 120 mg, 2 capsule(s), Oral, At Bedtime    albuterol (ProAir HFA 90 mcg/inh inhalation aerosol) 180 mcg, 2 Puff, Inhalation, q6h, for 90 day(s), PRN: as needed for wheezing, 3 Each, 3 Refill(s)    ascorbic acid (Vitamin C 250 mg) 250 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 3 Refill(s)    atorvastatin (atorvastatin 80 mg) 80 mg, 1 Tablet(s), Oral, Daily    budesonide-formoterol (Symbicort 160 mcg-4.5 mcg/inh inhalation aeros 2 Puff, Inhalation, bid, PRN: Shortness of Breath    cyclobenzaprine (cyclobenzaprine 5 mg) 5 mg, 1 Tablet(s), Oral, tid, PRN: Muscle Spasm, 60 Tablet(s), 0 Refill(s)    denosumab (Prolia 60 mg/mL subcutaneous solution) 60 mg, IM, Every 6 Months    diazePAM (diazePAM 5 mg) 5 mg, 1 Tablet(s), Oral, At Bedtime, PRN: Spasm    dicyclomine (dicyclomine 10 mg) 10 mg, 1 capsule(s), Oral, AC & Bedtime, PRN: Bladder Spasm    fexofenadine (fexofenadine 180 mg) 180 mg, 1 Tablet(s), Oral, Daily, PRN: Allergy Symptoms    furosemide (Lasix 40 mg) 40 mg, 1 Tablet(s), Oral, Daily, PRN: Swelling, 30 Tablet(s), 3 Refill(s)    lactulose (lactulose 10 g/15 mL oral syrup) 10 g, 15 mL, Oral, Daily, 480 mL, 4 Refill(s)    magnesium oxide (magnesium oxide 400 mg (240 mg elemental magnesium)) 400 mg, 1 Tablet(s), Oral, Daily, 0 Refill(s)    naloxone (Narcan 4 mg/0.1 mL nasal spray) 4 mg, IntraNasal, Once, may repeat every 2 to 3 minutes until patient responds, 2 Each, 11 Refill(s)  Instructions:may repeat every 2 to 3 minutes until patient responds  ondansetron (Zofran 4 mg) 4 mg, 1 Tablet(s), Oral, q6h, PRN: Nausea/Vomiting, 20 Tablet(s), 0 Refill(s)    oxyCODONE (oxyCODONE 10 mg) 10 mg, 1 Tablet(s), Oral, tid, 0 Refill(s)    pantoprazole (pantoprazole 40 mg oral delayed release tablet) 40 mg, 1 Tablet(s), Oral, bid    rifAXIMin (rifAXIMin 550 mg) 550 mg, 1 Tablet(s), Oral, Daily    spironolactone (spironolactone 50 mg) 50 mg, 1 Tablet(s), Oral, Daily    traZODone (traZODone 50 mg) 50 mg, 1 Tablet(s), Oral, At Bedtime, PRN: Sleep    umeclidinium (Incruse Ellipta 62.5 mcg/inh inhalation powder) 1 Puff, Inhalation, Daily, PRN: Shortness of Breath      Discontinued Medications  aspirin (aspirin 81 mg , chewable) 81 mg, 1 Tablet(s), Oral, Daily, 0 Refill(s)       Physical Exam at Discharge  Vitals & Measurements  T: 36.5 °C  TMIN: 36.5 °C  TMAX: 37.1 °C  HR: 73  RR: 25  BP: 134/81  SpO2: 90%  WT: 68.9 kg  BMI: 29.3      GEN: In no acute distress. HEENT: Mucous membranes moist, anicteric sclera without pallor. NECK: No thyromegaly or nodularity, no lymphadenopathy, no JVD, no carotid bruits. CARDIAC: RRR, normal S1/S2, no murmurs, rubs, or added sounds. trace BLE pitting PULM: Symmetric chest expansion. bilateral crackles, no wheezing ABDOMEN: Soft, without guarding. EXTREMITIES: 2+ distal pulses bilaterally, no edema. SKIN: Warm, well-perfused. No rashes or skin breakdown. NEURO: Alert and oriented to person, place, time. PSYCH: Appropriate mood and affect.   Follow Up Appointments     Follow Up Appt External Clinic or Provider, Clinic Name: (Privacy), Provider Name: (Privacy) Within 7 Days, Laboratory Tests   Follow Up Appt Medicine Cardiology, Clinic Name/Phone: (privacy) Provider Name: (privacy) Within 1 Month, No tests, Reason for Follow Up Clin f/u hospital discharge   Follow Up Appt Medicine General, Clinic Name/Phone: Other - see comments, Provider Name: (privacy), Within 14 Days, No tests, Reason for Exam hospital discharge, covid, chest pain    Appointment Type  When  With  Where  Contact Information  Status   NPC 01/20/2022 06:00 AM  Nurse Phone Call  Confirmed  GI Lab Anes 01/20/2022 07:00   Confirmed  RT1 02/14/2022 04:00 PM  Cardiology  Clinic Confirmed  PR1 04/28/2022 09:00 AM  Bone Health  Confirmed    Nursing/Other Orders   Heart Healthy (4gm NA, low fat). Ordered on 01/13/22 3:38:00, Meal Start Time Breakfast 0700 to 0900   Intake and Output. 01/12/22 15:06:47, Continuous Order, q12h. Order comment: Ordered by system rule: based on indications for congestive heart failure.   Intake and Output (I&O). 01/12/22 20:06:00, Continuous Order, total every 24 hours   Intake and Output (Strict I&O). 01/12/22 20:06:00, Continuous Order   Elevate Extremity. 01/12/22 20:06:0) As Indicated, Bilateral LE, Elevate legs while in bed or sitting., PRN Order?   Code Status. Code Status Description: Full Code     Addendum by (privacy) on January 13, 2022 13:03:09 (Verified)    I personally saw and evaluated the patient, independently performed the critical/key portions of the E/M service, and discussed the management with the resident/fellow on 1.13.2022. Chest pain likely due to pulmonary infection with pleuritic nature. Also reports chest palpitations with pulsatile feeling in L lower jaw when in afib. Given recent negative stress test and normal EF and wall motion by echo, not concerning for symptoms being from ischemia. May benefit from higher dose of nadolol during acute illness to prevent afib recurrence and may be able to go back to prior dose once she is recovered.