Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Troponin normal
Clinical narrative: Hospital HPI Patient is a 70 y.o. female with a PMH significant for bipolar disorder , anxiety/depression , fibromyalgia, osteoarthritis, aortic stenosis status post TAVR x2 in 2001 and 2019, CAD, AFib on Eliquis, hx of CVA on ASA/plavix, HTN, DVT s/p IVC filter, chronic diastolic heart failure who initially presented to the hospital on 5/28 to SLW as a stroke alert with aphasia, confusion, repetitive speech.  Not a tPA candidate given she is on systemic anticoagulation with Eliquis for Afib.  Imaging negative for hemorrhage, ischemia, and large vessel occlusion.  Patient was admitted to the ICU, she remained confused, but alert.  The next morning, the patient was found to be unresponsive and have twitching to bilateral sides of the face and left gaze for preference.  Seizure was suspected.  Patient was given Depakote and Ativan.  Neurology was consulted.  Patient was started on Vimpat.  No significant improvement in her exam.  Patient was intubated for airway protection, and transferred to hospital  for continuous video EEG monitoring.   Upon arrival to the ICU, the patient was intubated and sedated on propofol at 40. Sedation was held the patient became agitated.  Would not open eyes spontaneously, but was moving all 4 extremities equally and pulling at restraints.  Patient purposeful, but not following commands.  Attempting to sit up in bed.  Patient was initiated on video EEG monitoring to rule out intermittent seizure activity and postictal state.  Repeat labs drawn and electrolytes repleted.  Patient hemodynamically stable.  Patient started on Precedex for sedation.   Patient's daughter was updated via the telephone.  Patient's daughter reports that she was recently started on baclofen for her hip pain.  Patient was given a prescription which she filled on 5/26 for 20 tabs of 20mg each.  Patient's daughter reports that it is possible she could have taken more than the prescribed dose in order to make her pain better faster.  Daughter states she does not think she took the whole bottle, but is unsure of how many she took.  Patient's daughter also reports that she drinks alcohol daily, 10 oz glasses of gin and vodka."   Hospital Course Brief ICU course:  Patient intubated for airway protection and transferred about plan for continuous video EEG monitoring.  EEG was negative for any seizure activity and patient's antiepileptics were stopped.  LP and MRI were negative for any etiology of encephalopathy and neurology signed off.  Patient's mental status was eventually improving and encephalopathy was thought to be secondary to polypharmacy.  Throughout course she had multiple extubations a re-intubation but finally has been extubated since 6/10 and on room air.  Course was also complicated by acute blood loss anemia secondary to left flank/abdominal wall hematoma status post empiric embolization of T8 and T9 intercostal arteries.  Initial planning to transfer out to floor on 06/11 however prior to leaving ICU patient had episode of SVT and was kept for further monitoring.  During this event her Coreg was uptitrated and her home metoprolol was added without any more recurrent tachyarrhythmias.   Transfer to the floors with SLFM team on 06/14.  Patient's mental status had returned back to baseline.  Unfortunately on morning of 6/15 patient had an episode of burning chest pain and tachycardic to 150.  Alerted and evaluated at bedside.  EKG at that time showed AFib with RVR in the 130s.  Troponins were obtained which were 0.04 then trended down to 0.03.  Cardiology was consulted.  Patient's heart rate eventually returned to normal on own and chest pain gradually resolved.  Patient should not be on 2 beta-blockers, per Cardiology Coreg was stopped and her metoprolol dose was increased.  Patient was continued on IV Lasix for 1 more dose on 06/16 then transition to p.o. Home dose 40 mg daily.  Patient remain observed on tele and arrhythmia free, stable, mental status at baseline.  On day of discharge, patient remains stable and looked well, wanting to go home.  Cardiology cleared patient for home.  PT/OT recommended home with PT services.  Case management involved for  services at home.  Plan to discharge with PCP and cardiology follow-up. Advised that her abdominal wall hematoma will slowly shrink and pain will improve appropriately.   ---When calling patient to follow up, she stated her symptoms started 4 days after vaccination with COVID vaccine. Symptoms also started day after she reportedly by daughter and patient only taking 2 doses of Baclofen to me today 6/24/21. She presented to ED on 5/28, received COVID vaccine 5/24, and took two doses of Baclofen 5/27.