Age: 81.0
Sex: F
Vaccine: COVID19
Symptoms: Cerebral artery occlusion, Cerebral small vessel ischaemic disease, Chest X-ray normal, Computerised tomogram head abnormal, Computerised tomogram thorax normal
Clinical narrative: Pt received vaccine in her home state, unable to get details of vaccine administration such as date, site, lot #, etc.  Per ED MD note : 81-year-old female with reported history of atrial fibrillation found down at hotel room.  Patient states she has been on the ground in the room for 3 days, she was found covered in feces.  Alert and oriented x4 however intermittently appears confused and has varying history.  She does not know how she got on the ground, however denies fall or syncope.  No significant current complaints.  Slightly tachycardic and febrile, slightly hypertensive, exam without any significant acute findings, no obvious skin source of ulcer or infection, no focal neurological deficits, no pain.  Initiated aggressive fluid hydration and sepsis work-up.  EKG appears normal with no signs of ischemia or arrhythmia.  Labs show slightly elevated troponin, low magnesium, metabolic/lactic acidosis.  VBG relatively normal.  Urine negative for infection chest x-ray without evidence of pneumonia, no clinical signs or symptoms to identify source of infection.  Nothing to suggest meningitis at this time.  CT head is negative.  Unclear source of fever however empirically treated with antibiotics and fluids.  Patient remains hemodynamically stable with no hypotension.  She did arrive slightly hypoxic and with increased respiratory rate however clear lung sounds and no indications of heart failure, COPD/asthma.  CT chest without evidence of pulmonary embolism, focal pneumonia, or fluid overload.  Respiratory status possibly related to compensation for metabolic acidosis that is likely due to lack of fluid intake due to being on the ground.  CK is normal and kidney function is normal.  Consulted medicine for admission for further evaluation and treatment.  Cardiology was also consulted for NSTEMI, agrees with current plan.   per H&P 4/28/21:   Altered mental status (R41.82): Etiology is not clear. Patient states she had J&J Covid vaccine about 3 weeks ago. Need to rule out cerebral venous sinus thrombosis. Get a CT scan of the brain with contrast. If negative will get CT venogram or MRV and MRI of the head. Neuro checks. Request PT OT and speech therapy evaluation. Check urine drug screen. Check blood alcohol level.    Non-STEMI (non-ST elevated myocardial infarction) (I21.4): Start argatroban drip until cerebral vein sinus thrombosis is excluded then we can switch to heparin drip. Start aspirin and statin. Check fasting lipid panel. Monitor on telemetry. Trend troponin. Request echocardiogram. Cardiology to consult. Dr.  was consulted from the ER.      » Beta-Blocker Ordered: Beta-Blocker Ordered     » Aspirin Ordered: Aspirin Ordered     » Statin Ordered: Statin Ordered    Fall (W19.XXXA): Plan as documented above.    Rhabdomyolysis (M62.82): Hydrate and recheck CPK.    Elevated liver enzymes (R74.8): Check hepatitis panel. Monitor levels.    Fever (R50.9): No clear source of infection. Follow up on blood cultures.   CT chest negative for infectious process. Check CT of the abdomen and pelvis.Start empiric antibiotics: Vancomycin and Zosyn.    Hypomagnesemia (E83.42): Administer magnesium sulfate. Repeat level in the morning.    Diabetes (E11.9): Start sliding scale insulin. Monitor fingersticks. Hypoglycemic protocol.  Check hemoglobin A1c.    Hypertension (I10): Fortunately patient is hemodynamically stable. We will cautiously start metoprolol. Adjust antihypertensives to optimal blood pressure control.    Acidosis, lactic (E87.2): Likely due to profound volume depletion. Rule out sepsis. Hydrate and trend level.    VTE: Argatroban.      » VTE Prophylaxis Assessment: Risk Level documented as Low Risk    Discharge Planning:        » Discharge Planning:           » Discharge To, Anticipated: Home independently  Per Intensivist note 4/30/21: . Another consideration was TTP, however, patient has normal renal function with no significant evidence of microangiopathic hemolytic anemia (no schistocytes on smear). Also does not seem consistent with ITP. Suspect more a result from sepsis given bacteremia  Per attending note 4/30/21: Altered mental status (R41.82): Likely septic encephalopathy due to sepsis. No cerebral venous sinus thrombosis.  MRI negative for stroke. AMS has resolved.  Continue antibiotics.  Per attending note 5/2/21: Addendum by  MD,  on May 02, 2021 09:58:55 (Verified) Discussed with cardiologist, Dr. .  Possible need for TEE with regards to persistent bacteremia.  We will keep n.p.o. overnight for TEE tomorrow. Repeat blood culture from 4/30/2021 just came back positive for Enterococcus.  Suspect endocarditis due to TAVR.  ? need for TEE to evaluate the valves (TAVR) more closely.  Duration of antibiotics depends on bacterial clearance: To be determined.  Get another set of cultures.  On Zosyn.  per attending note 5/4/21:  Enterococcal bacteremia (R78.81): Etiology not entirely clear but suspect GI source or endocarditis.  Repeat blood culture from 4/30/2021 is positive for Enterococcus.  PCP he is accepting to follow-up for IV antibiotics management: Will arrange home IV infusion through  care .  Antibiotics end date to be determined: Pending bacterial clearance.  Repeat blood cultures pending.  Infectious disease specialist following: Patient is currently on Unasyn. Will need 4 weeks of IV antibiotics.