Age: 77.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Metabolic acidosis, N-terminal prohormone brain natriuretic peptide increased, Oxygen saturation decreased, PCO2 increased, Platelet count decreased
Clinical narrative: Elderly female from facility who had been manifesting cognitive deterioration. Pt was last seen in clinic on 9/18/20 with memory loss and multiple fall episodes. Facility staff reported unusual behaviors, such as writing on the walls, the toilet, the blinds in the windows. She also was noted to have difficulty decision making. Neurocognitive testing was requested. She had been in her usual state of health, until 2/5/21. administrator provided that the facility staff had earlier noticed that she was dragging her right foot and has been needing more assistance with activities. The patient was walking and did not feel well. She was lowered to the ground and had a a witnessed cardiac arrest. The ambulance was called and she was reportedly found to have pulseless electrical activity. She was given Epinephrine and Amiodarone with return of pulse. The patient was brought to the Emergency Room and was evaluated by ER physician Dr.. EKG showed atrial fibrillation, ventricular rate = 66, RBBB with Brugada pattern. She was emergently brought to the Cath Lab. Cardiac catheterization showed normal coronary arteries but EF 35-40% (non-ischemic cardiomyopathy). Repeat EKG showed atrial fibrillation with rapid ventricular response = 110, RBBB. Therapeutic hypothermia was initiated. The patient was admitted to the ICU on mechanical ventilation. COURSE IN HOSPITAL  The patient was admitted to the ICU and was followed by Pulmonary/Critical Care, Dr.  and Dr.   Patient was maintained on mechanical ventilation, sedated with propofol and fentanyl IV.  Vasopressors were administered (Levophed IV).  She was managed with therapeutic hypothermia.  She was followed by Cardiology, Dr. Foley catheter was inserted for close input/output monitoring.  Neuro checks, vital signs, daily weights, pulse oximetry, cardiac telemetry and fingersticks were monitored.  She was given sodium bicarbonate IV due to metabolic acidosis.  She was also given insulin IV drip.  Potassium chloride IV was administered due to hypokalemia.  The patient was given amiodarone IV.  Platelet count was noted to be low but stable.  Glucose levels were within acceptable range.  Metabolic acidosis resolved.  Hypokalemia resolved.  Hypomagnesemia resolved.  There were elevated LFTs which improved.  Elevated CPK also improved.  She was taken off hypothermia protocol.  Sedation was decreased and she was able to open her eyes with verbal stimulus but unable to follow commands.  Ammonia level was normal.  Neurology evaluated the patient.  EEG showed left periodic epileptiform discharges consistent with severe diffuse encephalopathy.  Chest x-ray revealed right upper lung and left mid lung increasing opacity for which meropenem IV was started.  Levophed was discontinued.  Initially she had peripheral cyanosis, but this resolved upon discontinuation of vasopressors.  Brain MRI was done demonstrating diffuse bilateral small and moderate-sized ischemic foci throughout the cerebellum and cerebellar region suggestive of embolism.  There also was chronic marked atrophy and moderate small-vessel gliosis.  Based on neurologic evaluation, her prognosis for meaningful neurologic recovery was thought to be extremely poor.  A decision was made by her friends and POA for comfort care measures only. Compassionate extubation was performed on February 12, 2021. The patient passed away on February 12, 2021, at 6:39 p.m.