Received Mar 31, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 2 | 043B21A | UN / UN |
BRIEF OVERVIEW: Admission Date: 3/25/2025 Discharge Date: Mar 26, 2025 Discharge Disposition: home or self care Active Issues Requiring Follow-up: Adherence to salt and fluid restricted diet please. Future Appointments Date Time Provider Department Center 4/1/2025 4:00 PM MD 5/13/2025 11:00 AM NP 6/19/2025 9:00 AM MD DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Dyspnea [R06.00] Atrial fibrillation with rapid ventricular response (HCC) [I48.91] Acute on chronic congestive heart failure, unspecified heart failure type (HCC) [I50.9] COVID [U07.1] HOSPITAL COURSE: He has had increasing shortness of breath over the past week with chills and fatigue. He noticed increased swelling to his lower extremities the past several days and intermittent chest pain, which he states is chronic for years. Denies productive cough, palpitations, abdominal pain, nausea, vomiting, or diarrhea. EKG on arrival revealed atrial fibrillation rate 129. Labs remarkable for hypomagnesemia, elevated BNP, and chest xray revealed mild pulmonary edema and bibasilar atelectasis. He is positive for COVID-19. These were his acute medical issues addressed: Chronic hypoxic respiratory failure - complicated by fluid overload, atelectasis, viral infection - presented with increasing dyspnea past week, wears 2 liters nasal cannula oxygen at baseline 99% sat in ED - recently treated for COPD exacerbation 2 weeks ago with steroid and antibiotics - chest xray with mild pulmonary edema, bibasilar atelectasis, and cardiomegaly - COVID- 19 positive - received 40 mg IV lasix daily. - duonebs prn/- continue home inhalers Paroxsymal atrial fibrillation - history of unsuccessful cardioversion - initial EKG with rapid ventricular response rate 129 - received 10 mg IV cardizem x 2, with successful rate control - sotalol/ eliquis/ telemetry Hypomagnesemia - Mag 1.5 -- > 2.0 today Chronic systolic and diastolic heart failure with recovered EF - concern for exacerbation - chronic bilateral lower extremity edema 2+ worsened past few days, chest xray with mild pulmonary edema - last echo 2/2023 EF 55-60%, mild diastolic dysfunction - BNP 2,553 - troponin normal - received 40 IV lasix daily - continue entresto and torsemide - echo pending COVID- 19 - symptom onset 7 days ago, shortness of breath, chills - isolation/ supportive care. No increase in O2 requirement over baseline. Stable and improved. Would like to keep another 24-48H for more diuresis. Patient however insistent on being discharged home today. DC home per his request. Continue all meds. Discharged to Home