Discharge Provider: DO Primary Care Provider at Discharge: None Physician, DO None Admission Date: 6/28/2022 Discharge Date: 6/28/2022  PRESENTING PROBLEM: Hypoxia [R09.02] Atrial fibrillation with RVR (HCC) [I48.91] Acute congestive heart failure, unspecified heart failure type (HCC) [I50.9] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 65-year-old morbidly obese male who presented to the emergency department for concerns for rapid heart rate over the past 2-3 days that is not going away.  Patient has a known history of atrial fibrillation and he is currently on Xarelto.  He denies missing any of his anticoagulation doses.  He also denies missing any doses of his PO cardizem which he states he is supposed to take 3 times a day despite being a 6 hour preparation.  He reports difficulty breathing, fatigue and rapid heart rate.  He also takes propanolol XL.  He came in today because his symptoms were not improving.  He denies any nausea vomiting chest pain or heaviness.  He was recently admitted for similar atrial fibrillation with RVR earlier this month however he left AMA because he was unable sleep in the hospital.  The ED staff spoke to his cardiologist who is familiar with this patient and he recommended continuing cardizem therapy and adjusting his dose to keep his rate under control.  I was contacted by the ED staff and agreed to admit him on a cardizem gtt.  I will increase his PO cardizem to 60 mg q 6 hours and monitor him on telemetry.  Will endeavor to maintain K >= 4.0 and Mg >= 2.0.  Will get echo when rate is better controlled.   Patient became agitated with nursing staff after realizing he was on a fluid restriction with a 2 g sodium diet.  Patient immediately asked for the doctor to come in and speak with him.  He told nursing staff that he would time this on his phone to make sure the provider comes promptly.  When the provider arrived the patient was angry that nurse told him he could not have his soda or Tacos.  I explained to patient that he is on a heart healthy diet with fluid restriction based on his current medical needs.  At this time patients heart rate was between 125 and 149. The patient then stated that" maybe I should just go home and never come back here".  I told the patient that I do not recommend him leaving due to his hypoxia related to a new COVID-19 diagnosis as well as AFib with RVR.  I explained to the patient that it takes time for the medication to work and that he should stay overnight to see things improve.  And also told patient that he would still need to be on a fluid restriction and thus low-sodium diet.  Once this was said patient made up his mind and stated "I wanna go home, where are the papers I need to sign".  I brought AMA paperwork to the patient and told patient that with him leaving against medical advice there is an increased risk of mortality due to his hypoxia and rapid ventricular rate.  Patient understood and paperwork was completed.  Patient was discharged home AMA.  Discharge Provider: MD Primary Care Physician at Discharge: NP Admission Date: 7/1/2022  PRESENTING PROBLEM: Hypoxia [R09.02] Longstanding persistent atrial fibrillation (HCC) [I48.11] Congestive heart failure, unspecified HF chronicity, unspecified heart failure type (HCC) [I50.9] COVID-19 [U07.1] Acute on chronic combined systolic and diastolic congestive heart failure (HCC) [I50.43]   HOSPITAL COURSE: The patient is a 65 y.o. male with a PMH of coronary artery disease, atrial fibrillation (on Xarelto), hypertension, hyperlipidemia, Stage 3 COPD(FEV1 of 42%),HFmEF (lowest 45%, now 35%)-ischemic cardiomyopathy, who was admitted on 06/28 secondary to decompensated heart failure, renal failure and found to be COVID-19 positive on 06/28 (placed on Paxlovid- d/c 07/02) who is being transferred to intensive care unit for worsening acute on the chronic hypercarbic hypoxemia respiratory failure and acute renal failure.     Presented on 06/28 secondary to dyspnea, and rapid heart rate consistent with atrial fibrillation with RVR.  Subsequent left AMA and re-presented on 07/01 due to worsening shortness of breath and lower extremity swelling consistent with heart failure exacerbation.  He was diuresed with 80 IV 2 times a day and thereafter transition Lasix drip on 07/03,Decadron 6 mg 0 7/0 1-present.  Hyper response called on 07/03 secondary to hypotension, hypoxemia placed on 6 L nasal cannula and thereafter BiPAP, and stat lab work revealed a a combination of respiratory and metabolic acidosis pH 7.2/pCO2 57.8, bicarb 20, worsening renal failure with creatinine of 3.5 (baseline 1.5), BUN 81.   Brief ICU Course: Upon presentation to the intensive care unit, was hemodynamically unstable, hypertensive, and bradycardic.  Stat blood work showed mixed respiratory and metabolic acidosis pH 7.21/pCO2 50, bicarb 17 and potassium of 7.1.  Telemetry concerning for high-grade AV block versus sinus bradycardia, atropine 0.5mg and calcium gluconate administered.  Bedside echocardiogram with significant LV dilation and decreased LV function (although poor windows).  He continued to remain hypoxic on 100% FiO2 on BiPAP, prompting need for intubation.    On 07/17/22, patient had episodes of desat and hypotension in supination and was subsequently kept pronated. He continued to detoriate over the course of 07/17/22 and 07/18/22 requiring multiple pressor support and sedation at which point comfort care decisions regarding patient prognosis were initiated with the family and the patient was transferred to comfort care on 07/17/2022.    Patient deceased on 07/18/22 at 1530.