Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Ischaemic stroke, Lacunar infarction, Lethargy, Low density lipoprotein normal, Malaise
Clinical narrative: Patient is a 80 y.o. female PMHx psoriasis, CKD, DM, hypothyroidism, HTN who presented from home on 10/26/2023 with CC AMS, arthralgias, generalized fatigue progressive over a couple of weeks. Found to have COVID-19 and an subacute ischemic stroke.  COVID symptoms have improved, encephalopathy resolved.  Neurology followed, patient will be on dual antiplatelet therapy for 21 days and follow-up in stroke clinic.  EP consulted, no evidence of arrhythmia while admitted, TTE unremarkable, MCT to be mailed to patient.  Patient will keep a close watch of her blood pressure at home with multiple medication adjustments made as below. She needs repeat BMP 11/2 to monitor creatinine.   Toxic metabolic encephalopathy - resolved - COVID-19, delirium d/t inflammatory response after flu vaccination, +/- stroke contributing - MR brain small subacute left frontal infarct, multiple chronic lacunar infarcts - discussed with neuro who feels stroke is tiny/not main driver of presentation - 10/28-30 back to baseline with supportive care, no focal weakness appreciated   Subacute left frontal ischemic infarct - Etiology: workup ongoing - ?thrombotic d/t hyper coag state (COVID-19) and vascular RFs - Presented with: encephalopathy as above - Labs/diagnostics:             EKG: NSR             Carotid US: in place of CTA due to CKD - < 50% stenosis b/l             ECHO: TTE with bubble unrevealing, similar to previous             HgbA1c: 6.0 10/27             FLP: LDL 189 (on lipitor 40 ) - Antiplatelets/Anticoagulation: continue home ASA 81, Plavix added for 21 days then discontinue Plavix and continue aspirin 81 mg daily - Statin: inc to lipitor 80 (recheck lipid panel 1 mo w/ pcp) - BP goal: Less than 130/80 - DVT prophylaxis: Heparin Subcutaneous - Telemetry - Neurology followed, they will follow-up with patient, EP asked to see (some ectopy on tele) -EP evaluated, no evidence of atrial arrhythmia, patient will receive MCT in the mail   COVID-19 - Lethargy, decreased appetite, cry cough - Symptom onset: 1 week prior to arrival (generalized sx a little longer 2-3 weeks) - Positive COVID-19: 10/26/2023 at hospital - Oxygen status: Room air - symptoms resolving with supportive care, monitor  Acute atraumatic right wrist pain  - crystal arthropathy possible, monitor for worsening/consider infectious, does have history of PsA (could be a manifestation of this) - she has moderate pain with large movements of right wrist, effusion/warmth - tolerates micro movements - no history of gout (this would be an atypical first presentation) , uric acid noted at 7.6 - XR without chondrocalcinosis but CPPD arthropathy is in ddx - ortho hand signed off - patient declined diagnostic tap - trial of topical diclofenac, if doesn't tolerate topical NSAIDs then could try oral steroids (CKD precludes oral NSAIDs)   IDDM2 - A1C 6.0 - Home Levemir 30 nightly, lispro 10 to 15 units TID AC.  Glipizide 5 mg  - continue Lantus 20 units nightly, sensitive SSI. Stopping glipizide at d/c.    Hypertension - History of accelerated hypertension.  Had not taken medications in several days prior to arrival - Continue home Norvasc but increase to 10 mg daily, stop atenolol and changed to coreg 12.5 BID (more alpha 1 block aid), continue hydralazine 100 mg 3 times daily, hold Lasix 20 mg daily and Cozaar 50 mg twice daily with AKI and keep BP log twice daily until repeat BMP 11/2 and PCP follow up   AKI on CKD stage IIIb - AKI improved - Cr 1.2-1.3 on admit, up to 2.0 (after resuming ACEi / lasix) but now improving - possible this is all CKD just lower than normal cr due to holding BP meds - stop lasix/ACEi for now   Psoriatic arthritis - Per history, not on DMARDs.  No longer on anti-TNF alpha inhibitors since 10/2022   Malnutrition - Suspected, appreciate dietitian evaluation