Age: 40.0
Sex: F
Vaccine: COVID19
Symptoms: Angiogram cerebral abnormal, Arteriogram carotid abnormal, Brain oedema, COVID-19, Cerebellar artery occlusion
Clinical narrative: Hospitalized 10/18/2021; COVID-19 positive 10/18/2021; fully vaccinated  Patient is a 41 y.o. female with past medical history of polysubstance abuse, ETOH abuse, non-ischemic cardiomyopathy with HVAD implant 12/22/2019 on ASA 325 mg and INR goal of 2.5-3.0 due to evidence of LV recovery, with LVEF 50% on echo 8/2021. Also with hx MVA due to ETOH abuse 8/2020 with SAH and right hip dislocation requiring surgical intervention, infected now on lifelong antibiotics. Patient states she fell about 2 weeks ago without injury, did not hit her head. States she tripped over her dog, but denies injury. About 1 week ago, developed significant headache that has been constant since, state headache better now but still there. Also has been feeling lightheaded and dizzy at times, so decided to come get checked out. Went to ED, CTH showed multiple areas intraparenchymal bleed and SAH. Also complained of dry cough for about a week, intermittent nausea and fatigue with poor oral intake over the last week. Taking in fluids ok, but hasn?t been eating much. Denies fever/chills, shortness of breath, orthopnea, abdominal pain, drainage from driveline. States has had some dried blood on driveline dressing changes, but no active bleeding. Denies vision changes, gait disturbances, slurred speech, unilateral weakness or other complaints at this time.  ASSESSMENT / PLAN Recent Fall without head injury Headache with evidence of Multiple acute right cerebral hemisphere intraparenchymal hemorrhages, as well as mild SAH.  - per CT from hospital - INR 2.9 at Mercy, given 2.5 mg vitamin K and 2 units of FFP.  - hold coumadin and ASA for now, until cleared to restart from neurosurgery. - consult neurosurgery. Per ED, talked to neurosurgery who stated no acute needs at this time with no neurological changes. Will likely need follow-up CT head.  - neuro checks, monitor for changes.   Hx Non-ischemic Cardiomyopathy/Cardiogenic shock s/p HVAD implant 12/22/19 - previously on ASA 325 mg and coumadin (goal INR 2.5-3 due to LV recovery). Will hold for now with brain bleed. - last echo 8/16/21: LVEF 50%, RV normal. - await recommendation from neurosurgery on when ok to resume OAC. - multiple low flow alarms - consistent with LV recovery/suction events. Previously decreased HCT on pump to decrease alarms. Will give IVF resuscitation due to decrease oral intake. - continue BB and Entresto. Monitor BP. - monitor INR and LDH. COVID 19 + - patient with cough and poor appetite, no other symptoms. Symptoms started about 1 week prior. - O2 sats stable on RA. Defer treatment at this time. Monitor for progression of symptoms. 10/22/2021 note: ASSESSMENT / PLAN Plan for today: -supra therapeutic INR  s/p vitamin K 2.5 mg po & 2 units FFP -Neurosurgery recommended 10 day hold of ASA & Coumadin. Coumadin was restarted at 3mg on 10/20 with goal to keep INR <1.5 for 7-10 days post bleed - appreciate neurosurgery comments/recommendations- plan to repeat head CT 10/22 afternoon and if stable- will start low intensity  heparin with NO initial or subsequent boluses- then once therapeutic for 24 hours follow up CT head  -stroke neurology team consulted per Neurosurg recs  Multiple acute right cerebral hemisphere intraparenchymal hemorrhages, as well as mild SAH 10/18/21 Headache for 1 week prior to admit -recent fall without head injury PTA, only complaint is of HA x 1 wk, maybe intermittent blurry vision but no focal weakness - per CT from hospital - INR 2.9 at hospital, given 2.5 mg vitamin K and 2 units of FFP->INR on 10/19 am=1.5  - Coumadin 3 mg HS since 10/20 for new INR goal 2-2.5, but will keep < 1.5 for 7-10 days post bleed - Neurosurgery team appreciated  -10/18 CTA Head/Neck with right M1/M2 near occlusive, stenosis likely subacute thrombosis -10/18 am CT Head with right MCA cortical & SAH with surrounding edema, favored hemorrhagic conversion of subacute infarct -repeat CT Head 10/18 early afternoon as recommended by NeuroSurg=no acute change - neuro checks q 4hr COVID 19 + - patient with mild cough and poor appetite, no other symptoms. Symptoms started about 1 week prior - O2 sats stable on RA. Defer treatment at this time. Monitor for progression of symptoms. - she was given Janssen vaccine 8/18/21