Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Brain oedema, COVID-19, COVID-19 pneumonia, CSF test normal, Cardiac assistance device user
Clinical narrative: Discharge Provider: MD Primary Care Physician at Discharge:  PA  Admission Date: 4/10/2023  PRESENTING PROBLEM: Generalized weakness [R53.1] Acute kidney injury [N17.9] Pneumonia of both lungs due to infectious organism, unspecified part of lung [J18.9] Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1] Status epilepticus [G40.901]   HOSPITAL COURSE: Patient is a 72 y/o female w/PMH of PRES, HTN, DVT/PE on coumadin, CKD3, COPD, severe PAD s/p fem-fem bypass and balloon angioplasty, and previous hospitalization for COVID pna in 11/2022 who was admitted on 4/10 for COVID-19 and suspected superimposed bacterial pneumonia. She received treatment with 5-days of ceftriaxone and 10 days of Decadron. Her course was complicated by a RAP early 4/15 for seizure-like activity, Neurology initially placed on cEEG and given a dose of keppra, but was discontinued due to lack of epileptiform activity. RAP was called again early 4/17 for seizure like activity along with associated aspiration concern, ultimately found to have EEG evidence of status epilepticus and given 3mg ativan and 4500mg IV keppra load along with transfer to ICU. CT head was concerning for ischemia vs PRES, so MRI brain performed with cytotoxic and vasogenic edema c/w PRES and CTA H/N showed severe stenosis of left PCA and subclavian artery. The patient had refractory status epilepticus on 4/17 and was subsequently loaded with vimpat and intubated for airway protection. She required NE after intubation. She underwent LP by IR on 4/19, with CSF not concerning for infection. Antiepileptics were managed by neurology with escalating doses of Keppra, Vimpat, Onfi, and Topamax. EEG report 4/20-4/22 was first period of no seizure activity.  EEG on 4/23 noted severe underlying focal cortical irritability of the type seen with acute cerebral lesions and prolonged status epilepticus. The focal spikes indicate ongoing risk of left temporal and left occipital seizures. She developed shock with fluctuating vasopressor requirements and low grade fever so antibiotics were started 4/23. Blood cultures were obtained and revealed no growth to date. With little improvement in mental status, repeat MRI brain was requested and showed resolution of previously seen posterior cerebral edema. Patient had increasing vasopressor requirement, increased secretions, fever. Repeat cultures were again obtained and showed no growth to date. Her hypotension required IVFs and norepi to maintain an adequate MAP. Neurology continued AED weaning, but the patient remained unresponsive.  On 4/30 a phone conference was completed with her sons and they wished to pursue comfort care. Hospice was consulted and graciously managed her end of life care. She was extubated and her pressors were stopped. At 0143, she was found without spontaneous pulses or respirations. Her pupils were fixed and dilated. She was pronounced deceased at that time. Dr. was aware and will sign the death certificate. Greater than 30 minutes was spent on this discharge.    Medical Examiner Case Assessment Select Applicable Patient Criteria: Does not meet any of the listed criteria  Date of Death: 5/1/23 Time of Death:  1:43 AM Preliminary Cause of Death: Status epilepticus