Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Bradycardia, Brain oedema, CHA2DS2-VASc-score, Cardiac failure, Caregiver
Clinical narrative: Presents here today for hospital discharge follow-up.  She is actually a new patient here, first visit at our practice today.  Patient is here with her daughter.  She was in the emergency department on 1/31/2022 via EMS complaining of severe headache x3 days with onset of blurred vision on day of ER visit.  She reported getting a Covid booster on 1/27/2022 and waking up and feeling quite poorly.  Complaining of headache mostly on the right side but also noticed her vision was off.  Hard time describing but mostly the vision was described as blurry.  She has had a history of migraines but felt like this headache was different.  She denied any neck pain or fever.  No cough or cold symptoms.  Her vision continue to be worse so she came in to the ER.  She thought maybe her blurred vision had something to do with fentanyl patch so she took her fentanyl patch off.  Her neuro exam/NIH score 2 for complete hemianopsia of the left side.  She did have some weakness in the left leg but apparently chronic.  Her blood pressure slightly elevated at hospital.  CBC and BMP grossly normal.  Troponin negative.  EKG grossly normal.  Head CT showing moderate sized area of cerebral edema involving the right temporal occipital lobes concerning for acute ischemia/infarct.  Due to symptoms for 3 days she was not a candidate for TPA.  She was given aspirin and recommended for admission to the hospital.  During hospital admission she had an echocardiogram done showing stage I diastolic dysfunction with preserved EF, no echocardiographic evidence of a cardiac source of emboli.  Consider TEE if indicated.  MRI MRA of the neck was done.  Acute ischemic area of right occipital lobe and posterior right temporal lobe consistent with findings on prior CT.  MRA of neck show no stenosis or occlusion.  As noted her history of atrial fibrillation.  Other than vision changes she was felt to be neurologically intact without obvious focal deficit.  Not a TPA candidate.  Due to the size of her stroke she was also not started on antiplatelet therapy due to risk for hemorrhagic conversion.  She did get a loading dose of aspirin.  She was admitted to the PCU.  Neurology was consulted and felt that due to the size of her stroke holding off on anticoagulation for a week.  They discussed with the neurologist starting Eliquis on 2/8/2022.  It was noted she had normal A1c.  LDL 91.  Evaluated for PT OT and felt to be safe for discharge.  She was instructed to not drive.  She was instructed on smoking cessation.  She was advised to start Eliquis and high intensity statin within a week.  Outpatient ophthalmology neurology and PCP follow-up recommended.  There is mention of her history of A. fib.  Not on beta-blocker due to bradycardia.  Not on anticoagulation for unclear reasons.  They are going to proceed with Eliquis as noted above.  She was recommended to  continue her other home medicines as prescribed.  She was admitted to the hospital on 1/31/2022 and discharged on 2/1/2022.   Today she advises doing well.  She continues with left eye vision loss lateral portion.  She has no further headache.  She has had no new neurological manifestations or deficits.  She has arranged follow-up with neurology and ophthalmology.  She has an arranged visit with PCP here next month as well.  As far as her current situation her daughter feels like the patient might benefit from a low-dose antidepressant.  She believes her mood has been low.  She has a lot of stress at home helping to care for her husband who is ill.  Now the patient has her own health concerns as well.    On review of her record she has been a longtime patient at UVA primary care in Stuarts draft.  Her medical history to include hypertension, cigarette smoker, chronic pain from a history of degenerative disc disease in the spine as well as kyphosis.  She is followed by pain management clinic and maintained on a high MME of narcotics for quite some time.  She is on oxycodone as well as fentanyl and muscle relaxer.  There is a history for her having some blood loss anemia in which she was hospitalized briefly around 2016.  As best I can tell she had a short spell of A. fib during the hospital stay which seemed to be quite transient and self-limiting.  She did end up following up with cardiology.  It has not been felt she has persistent A. fib.  Her most recent cardiology consult 10/29/2021 she was thought to be quite stable.  She had not had an echo in a while and was recommended echocardiogram.  She also wore a 48-hour monitor which showed no arrhythmia, particularly no A. fib or flutter.  Her CHADS2 score was 1.  She was not felt to need anticoagulation.  Her cholesterol profile has been quite good without any need for statin therapy.  She is not diabetic.   Her physical exam today grossly normal.  Her vitals grossly normal with the exception of elevated blood pressure.  She is not been taking blood pressure medicine, will restart lisinopril 20 mg, see below.  As regards her stroke etiology in my opinion seems uncertain based on her work-up.  What seems to be quite clear is she had a Covid booster on 1/27/2022 and her symptoms started within 24 hours of the Covid booster.  I am going to write this up in the VAERS system as an adverse reaction, and I would be cautious about any further mRNA vaccination at this point.  Otherwise she will be maintained on secondary prevention with Lipitor 40 mg daily.  Will work on better blood pressure control.  She has been educated on smoking cessation.  She has been asked to start Eliquis 5 mg twice daily starting on 2/8/2022 per the hospital neurologist.  I would like her to see the cardiologist in follow-up as well.