Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Blood thyroid stimulating hormone normal, Brain natriuretic peptide increased, Bronchial wall thickening, CHA2DS2-VASc-score, Cardiac failure congestive
Clinical narrative: Patient reports immediately after her vaccination she started noticing she did not feel well, the nurse checked her BP and HR and per immunization clinic note: "Patient c/o of rapid heart beat, BP- 146/108, HR 154, recheck BP 140/94, HR 94. Advised to follow up with PCP concerning next vaccine". She was sent home and that night she felt very fatigued. The next night she had chest pain with palpitations and continued to have repeated episodes where she felt like her heart was very fast. On 3/11/2021 while raking leaves in her yard she had worsening chest pain and shortness of breath and felt like her heart was beating fast so she presented to the emergency department. Upon presentation to the emergency room.  Upon presentation to the emergency room, blood pressure was 164/117 with a heart rate of 156 and respiratory to 35 pulse currently 93% on room air and later 94. EKG showed atrial fibrillation with rapid ventricular response of 151. Labs revealed hypokalemia of 3.1 and BNP of 359 with high-sensitivity troponin I of 18 and fibrin derivatives D-dimer of 2597.24 with unremarkable CBC except for mild anemia. Her influenza antigens came back negative and COVID-19 PCR came back negative. Chest x-ray showed cardiomegaly with small bilateral pleural effusions and interstitial thickening suspicious for pulmonary edema with overall findings consistent with CHF. Given elevated D-dimer chest CTA came back negative for PE and did confirm CHF with moderate bilateral pleural effusions and adjacent compressive atelectasis, pulmonary edema and cardiomegaly with prominent subcarinal and mediastinal lymph nodes that are likely reactive.. The patient was given 10 mg of IV Cardizem twice as well as 40 mg of IV Lasix. She was still tachycardic and started on IV Cardizem drip after an additional bolus of 10 mg given elevated blood pressure. She was admitted to stepdown unit for further evaluation and management.  Cardiology consult 3/12/21: HPI: 72 y.o. female with no apparent previous history of cardiovascular disease who has had significant progression of severe shortness of breath weakness fatigue PND and orthopnea over the last several weeks. The patient did get apparent Covid shot for which she has had a significant amount of symptoms thereafter. Currently the patient was admitted to the hospital with chest x-ray with pleural effusions and pulmonary edema troponin level has elevated to 18. She did have an EKG showing atrial fibrillation with rapid ventricular rate now slightly improved with diltiazem drip. She was placed on Eliquis with no bleeding complications. Currently with intravenous Lasix she has had some improvements of her pulmonary edema and shortness of breath. There is no evidence of angina or myocardial infarction at this time Assessment: 72-year-old female with acute systolic dysfunction congestive heart failure and acute atrial fibrillation with rapid ventricular rate without evidence of myocardial infarction Plan: 1. Continue intravenous Lasix due to continued pulmonary edema throughout the next 24 hours, 2. Continue anticoagulation for further risk reduction in stroke with atrial fibrillation, 3. Continue diltiazem drip for heart rate control below 100bpm although will add oral beta-blocker for better heart rate control, 4. Echocardiogram to evaluate for LV systolic dysfunction or valvular heart disease  Discharge Summary 3/13/2021:  1. New onset atrial fibrillation with rapid ventricular response: on metoprolol 100 mg bid. Cardiology added cardizem CD--much improved in 100's, TSH wnl. Her CHA2DS2-VASc score is 4.  She will beon p.o. Eliquis. 2D echo Left Ventricle: LV EF 35-40%. The LV has moderately decreased function. The LV demonstrates global hypokinesis. The LV internal cavity size was mildly to moderately dilated. There is mild LVH. LA, RA dilated   2. New onset acute systolic CHF: Diuresed with IV Lasix-- change to PO Lasix for 20 mg daily. 3.  uncontrolled HTN--new-pt's BP on ER 164/117, 148/83-- much improved with Metoprolol and cardizem. Cardiology Follow up:  NM stress test (5/11/2021) EF 46% with fixed defect in anterior, mid anterolateral, apical anterior and ischemia in the mid anteroseptal distribution. EKG 10/18/21: Sinus bradycardia, Atrial premature complex, RSR' in V1 or V2, Prolonged QT  Echo 10/25/21: EF: >55%, NORMAL LV SYSTOLIC FUNCTION, NORMAL RV SYSTOLIC FUNCTION, MILD AR, MILD MR, MILD PR, MILD TR, NO VALVULAR STENOSIS, TRIVIAL PERICARDIAL EFFUSION Left Heart Cath (11/5/2021): mild non-obstructive CAD Pa