Age: 84.0
Sex: F
Vaccine: COVID19
Symptoms: Anticoagulant therapy, Anticoagulation drug level above therapeutic, Arteriogram carotid normal, Asthenia, Atrial fibrillation
Clinical narrative: Moderna Dose 1 2/9/21 (012M20A) Moderna Dose 2 3/9/21 (036A21A) Moderna Dose 3 11/16/21 (lot NA) COVID Positive 1/19/22  1/19/22: 84-year-old female with atrial fibrillation anticoagulated on warfarin, mitral and tricuspid valve repair, ASD repair with recurrent left-to-right shunting, heart failure with preserved ejection fraction, severe pulmonary hypertension, aortic stenosis, COPD and obstructive sleep apnea presented with shortness of breath and weakness. Poor historian.  Patient reports progressive shortness of breath and dyspnea with exertion, decreased stamina.  She had maroon colored stool and an episode of bloody vomiting.  Denies previous history of bleeding, reportedly had normal colonoscopy several years ago.  Feels dizzy and lightheaded.  She was hospitalized from January 4, 2022 through January 10, 2022 for hypoxic respiratory failure Healthcare associated pneumonia supratherapeutic INR.  At the time of discharge INR was 1.6 and on follow-up with her PCP to was 2.5 on 01/14/2022.  Blood pressure 89/46, heart rate 106, respiratory rate 18 and SpO2 97% on room air.  Hemoglobin 4.0 baseline is around 9, INR 6.0, lactic acid 3.1 otherwise unremarkable CMP and CBC. COVID-19 PCR is positive, portable chest x-ray is pending. Patient is scheduled to receive 2 units of PRBC, FFP vitamin K.  2/3/22: The patient presented to the hospital on January 19th with AMS, shortness of breath and generalized weakness, borderline low blood pressure, not respiratory distress and not hypoxic, found her hemoglobin is 4 and her INR 6.0 while she is on warfarin for permanent AFib, her COVID-19 test came back positive but she did not require oxygenation at the beginning.  She was pale and she had hematemesis and melena, the patient received vitamin K and fresh frozen plasma to reverse the supratherapeutic INR with acute symptomatic upper GI bleeding, the gastroenterologist consulted and the patient had her 1st EGD and show large hiatal hernia with esophageal ulcers. She was on IV pantoprazole then switch to p.o. pantoprazole with Carafate.  The patient transfused 5 U of packed red blood cells with improvement in her hemoglobin.  Echocardiogram show EF 55% with indirect signs of severe pulmonary hypertension.  Known to have COPD.  Brain MRI negative for stroke, angiogram negative for significant carotid stenosis.  Then the patient started to develop sputum productive cough with shortness of breath and became hypoxic requiring 1-3 L of oxygen through nasal cannula, chest x-ray show worsen bilateral infiltration with pleural effusion, CT chest show bilateral small pleural effusion with focal basal consolidation.  Most likely the patient had aspiration pneumonia on top of COVID-19, initially she was on dexamethasone and remdesivir and supportive treatment but the remdesivir.  The patient blood pressure low most likely combination of medication and hypovolemia from GI bleeding and high likely autonomic dysfunction, started on midodrine 10 t.i.d. with improvement in her symptoms.  Will stop metoprolol and continue digoxin and other cardiac medication.  Discussed with the gastroenterologist when it is safe to restart warfarin given her high risk of embolic stroke, the patient had her 2nd EGD and show improvement in her esophageal ulcers without gastric or jejunal ulcer and the patient recommended to have PEG tube due to high risk of Bell's esophagitis and her large hiatal hernia contributing in reflux of the food and pelvis into her esophagus as it shown by her chest CT.  The patient had PEG tube placed and start on tube feeding, she will be able to have p.o. fluid intake coding water and juice and Jello and ice cream.   Currently her INR 1.0, warfarin resume, follow-up on INR and goal to be between 2.0-3.0, follow-up with PCP next week with repeated INR and BMP.