Age: 76.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Tremor, Troponin I normal
Clinical narrative: 03/09: presents to the ED with palpitations that began 90 minutes prior to arrival.  The patient has a history of paroxysmal atrial fibrillation but has not had an event for many years.  She had her second Covid vaccination yesterday and did have flulike symptoms including headache, myalgias, and shakiness through the last night.  She wonders if this triggered her symptoms.  No chest pain, dyspnea, or lightheadedness. 23: 18.  Cardizem 17.5 mg IV.  03/10 still in ER 00: 17.  The patient is discussed with hospitalist. would not recommend admitting the patient given her stability.  The patient's atrial fibrillation responded very well to the IV Cardizem.  Her atrial fibrillation is now in the 80s.  She is asymptomatic.  CHA2DS2-VASc score of 2. 00: 18.  Cardizem 30 mg p.o.  The patient is quite concerned about stroke.  Her mother died of CVA.  We will start anticoagulation today pending cardiology follow-up.  Eliquis 5 mg po. Recommended follow up with cardiology  03/16  visit with cardiology Paroxysmal atrial fibrillation Established Recently symptomatic with RVR after Covid vaccination Rhythm controlled with flecainide 100 mg twice daily Rate controlled with diltiazem 120 mg daily ? CHA2DS2-VASc Risk Factors/Score:        AGE(>=75), Female Gender and  3 points: "moderate-high" risk  - Stroke risk as 3.2% per year and 4.6% risk of stroke/TIA/systemic embolism. o HAS-BLED Risk Factors/Score:        Age > 65 years and 1 Points - "Low Risk" - 3.4% annual risk of major bleeding in one validation study and 1.02 bleeds per 100 patient-years in another validation study. Continue Eliquis 5 mg twice daily for embolic prophylaxis (creatinine 0.76 on 3/9/2021)  04/02 appt with PCP for ER follow up Patient is here today for ED follow-up on A-fib. Patient stated she is not taking Eliquis.   She had no side effects from her first COVID-19 vaccine. After the 2nd one she had muscle aches, headache, freezing cold, and "weird", and felt really badly then at 9:30 PM, 32 hrs after the 2nd vaccine dose she felt the a-fib started. She had not been in a-fib in many years. Cardiology had already recommended eliquis but she was holding off. She had diltiazem from 2017 that she tried but with out relief. They rate controlled her but she remained in a-fib, started eliquis, and she went home. For 2.5 weeks she had headache and chest pain, other muscle pain, felt horrible, until she stopped the Eliquis.  Since stopping the Eliquis, she still has occasional mild chest pain, and headache, and flushing. Her current chest pain is left chest, not radiating. The quality varies, stabbing pain in a very small location at times, may be associated with eating.  04/20 ER visit: Patient is a 76 y.o. female who presents with palpitations that started this evening, sudden onset, has a history of paroxysmal atrial fibrillation, and is maintained on 100 g of flecainide twice daily and diltiazem daily.  She also has short acting diltiazem 60 mg tablets to take for episodes of breakthrough arrhythmia.  She took a 60 mg short acting diltiazem prior to arrival She endorses some chest pressure with this though not severe, denies any dyspnea diaphoresis or nausea Not anticoagulated  04/29 Follow up with PCP For years she has been well controlled on low dose methimazole. Recently she has had 2 bouts of a-fib, when trying eliquis prescription and again following her 2nd COVID-19 vaccine. Upon recheck her TSH remains suppressed and FT4 elevated. Increasing from 5 to 10 mg methimazole now.  Left side of thyroid is palpably thickened with no nodules noted. Recommended Ultrasound. Explained that if nodules are seen, a follow up image may be indicated to assess nodule activity. Not in a-fib today.  C/o general malaise, shakiness, chest tightness, & flushing. Graves since 2006  She is feeling out of sorts, shaky, flushing, chest tightness, recurring headache. She has to stop and rest when trying to do activities as she will feel weak. Not sleeping well.  Systolic BP labile, from 105, to 155, to 135.