Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Toothache, Ultrasound Doppler, Venogram
Clinical narrative: Patient is a very pleasant 75-year-old female with a past medical history significant for COPD chronically on 2 L of oxygen, hypertension, type 2 diabetes which is diet controlled and oral Metformin controlled, hyperlipidemia, GERD, anemia, past history of PE and DVT diagnosed in January 2021 following COVID-19 infection currently on Eliquis compliant twice daily and kidney stone history who presented with worsening exertional chest tightness and shortness of breath as well as nausea for the past 2 weeks.  Patient reported she got to the point that she was hardly able to walk due to her exertional shortness of breath and chest tightness and needed to be evaluated.  She also reported some nausea as well as some headaches that have come on around a similar timeframe.  She also reported some poor dentition and mild dental pain and has been having a difficult time getting into a dentist due to her Medicaid and lack of coverage.  She has a history of hospitalization from January 30 to February 25 for sepsis secondary to healthcare associated pneumonia and UTI and at that time was treated with vancomycin, azithromycin and cefepime during that hospitalization she was noted to have a new onset left peroneal vein DVT and peripheral PE which was thought secondary to possibly her past history of Covid infection from December 28, 2020.  She was placed on Eliquis twice a day.  During her lengthy hospital from January 30 to February 25 she had bacteremia with Enterococcus and echocardiogram showed a possible pacemaker lead vegetation and therefore her pacemaker was removed on February 12 and she was discharged to rehab for 6 weeks of ampicillin and ceftriaxone which was completed on March 23, 2021.  She was then ultimately discharged home.  She had follow-up with cardiology who felt that she no longer needed to have a pacemaker and it was therefore left out.  She reports she was doing well up until about 2 weeks ago when she began to have the shortness of breath.  She received her COVID-19 vaccines on 3/18 and 4/16.  She reported after the 2nd one on4/16 she was ill with significant fatigue and fever and malaise.  She reports she completely recovered from that but again began having shortness of breath and exertional chest pain 2 weeks ago which prompted her current admission.  She was subsequently admitted to the hospital and ultimately underwent a CTA of the chest when her D-dimer was noted to be elevated at 1800.  CTA of the chest revealed a new left lower lobe pulmonary artery emboli with right heart strain.  She subsequently underwent an echocardiogram which did not reveal any evidence of acute heart strain.  She had a CT venogram of the head and subsequent MRI of the brain which revealed no cavernous vein thrombosis and no acute abnormality other than possible mastoiditis which may be chronic.  The case was reviewed with hematology and her Eliquis was discontinued and she was placed on Lovenox injections twice daily.  She was educated on administering these injections herself.  She will be following up with hematology as an outpatient for close monitoring.  She was also placed on an antibiotic for her dental caries and the mastoiditis as she did complain of the nausea and persistent headache and we arranged dental follow up on dc.  At this time she is felt stable for discharge to home.  She remains with some shortness of breath above her usual baseline but feels that it is getting better each day.  Her O2 sat is 95% on her usual 2 L of oxygen.    Reason for report:new PE of the left lower lobe -radiologist  who reviewed past cta chest from jan and reports that that old small pe is gone and this is a new much larger PE in a different location Sx's started and worsening the last few weeks pta She has been compliant with her eliquiss twice a day Venous dopplers neg and previous dvt of the L peroneal vein seen 1/30/21 and re imaged on 2/21/21 was also noted to be gone Pt had her 2nd covid 19 vaccine just last month 4/16/21 Current echo shows no R heart strain and nl ef  started on lovenox bid per hematology beta 2 glycoprotein IgG and IgM, antiphospholipid ab's are negative