Age: 87.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Acute kidney injury, Angiogram, Anticoagulant therapy, Aphasia, Atrioventricular block
Clinical narrative: Hospitalized;  COVID-19 positive 8.25.21 (fully vaccinated)   Admission Date: 8/25/2021 Discharge Date: 9/1/2021   PRESENTING PROBLEM: Patient is a 87 y.o. male with history coronary artery disease, hypertension, hyperlipidemia, hypothyroidism, insulin-dependent diabetes, obesity, and recent subdural hematoma status post burr hole as well as recent MCA stroke with seizures who presented to the ER from his rehab facility with concern for aphasia/confusion.               It is reported that there is a COVID outbreak on the floor he resides on at the nursing home. His wife spoke with him around 9 am the morning of presentation and he reported feeling ill and had a fever. He tested positive for COVID and shortly after he was brought to the hospital with concern for abnormal speech/confusion.  The patient was evaluated by Neurology in the ER, loaded with Keppra 20 milligrams/kilogram. In the ER, vitals remained stable, afebrile, normotensive, O2 sat 98% on room air. Labs showed mild AKI with creatinine 1.23, stable hemoglobin 11.1, no leukocytosis.  EKG showed normal sinus rhythm, 63 ppm, first-degree AV block.  Confirmed COVID positive.  CT head, CTA head/neck, and CT brain perfusion did not show acute pathology, fairly stable interval imaging.  Neurology recommended admission to Medicine for MRI brain, EEG monitoring, and workup for stroke.  The patient was admitted to Internal Medicine for further evaluation and treatment.   HOSPITAL COURSE: Multiple small embolic subacute ischemic CVAs of both hemisphere CTA head/neck: multiple areas of narrowing/stenosis without large vessel occlusion CT brain perfusion: large, chronic left holohemispheric cerebral convexity subdural hematoma, and a small, resolving, chronic right PCA territory. There is apparent ischemia within the bilateral cerebellar hemispheres, which is favored to be artifactual. No acute core infarction is apparent.  -MRI brain w/o contrast: 1. Stable bilateral subdural hematomas and stable associated mass effect.  2. 6 mm focus of early subacute ischemic infarction in the right putamen without hemorrhagic transformation. 3. Small noncontiguous foci of subacute ischemic infarctions in the right PCA distribution without hemorrhagic transformation. 4. Stable late subacute/early chronic infarction in the right temporal occipital region. There is stable petechial hemorrhagic transformation without space-occupying mass effect of this infarction. 5.  There are numerous tiny chronic infarctions throughout the cerebellum. 6.   Focal and more confluent areas of hyperintense T2 signal are noted in the periventricular and in the subcortical white matter. This is nonspecific. Statistically however it is most consistent with mild  chronic small vessel ischemic change of the white matter. 7.   Age-appropriate brain atrophy.    -Echo: left ventricular ejection fraction is 65%. No clear evidence for regional wall motion abnormalities noted but not all walls are seen well in all views. The mid and distal right ventricular free wall appear to contract well. The base is not well visualized. Today's study was compared to one performed on 7/28/21. The LVEF was 63% on the prior report. -LINQ implanted on 8/30, if having A. fib than he can be started on Amiodarone per EP -continue statin -aspirin 81 mg started on 8/31 after discussion with patient and wife, who are in agreement to start it [Neurosurgery: Recommend holding ASA indefinitely if able, but if pt must continue ok to restart] -PT/OT recommended subacute rehab, and he was transferred on 9/1/2021  -he should follow up with neurosurgery in 2 weeks and with neurology clinic    Seizure  - cEEG: The inpatient video EEG reveals epileptiform abnormalities involving the right temporal and left frontocentrotemporal head regions, consistent with an increased risk of focal seizures. There is a severe degree of multifocal bihemispheric slowing, consistent with a focal cerebral dysfunction involving the indicated regions. There is also a mild degree of generalized slowing, consistent with a diffuse cerebral dysfunction or encephalopathy - continue Keppra 750 mg bid, when taking 1000 mg bid, he was too sedated  -follow-up with epilepsy clinic in few weeks   Recent bilateral SDH (L>R) with MMA embolization (7/21/21) SDH stable on interval imaging Continue daily Provigil Asa 81 mg daily started on 8/31, watch closely  Neurosurgery recommending to hold ASA indefinitely if able, but if patient must continue okay to restart. Plan to repeat imaging in 6-8 weeks (First week Oct).   Patient to follow-up in neurosurgery clinic in 2 weeks. Has absorbable sutures at forehead, wound healing well   Dysphagia  SLP: thin liquids, regular solid (cracker/cookie), liquids via cup and no straws     Asymptomatic COVID-19 positive Tested positive at rehab facility 8/25, confirmed in hospital s/p Pfizzer COVID-19 vaccine Jan/Feb OK to transfer