Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Mechanical ventilation, Mental disorder, Metabolic encephalopathy, Motor dysfunction, Normocytic anaemia
Clinical narrative: Two days following first dose Moderna Vaccine at Pharmacy, she suffered a cardiac arrest.  Below  Discharge Summary From 3/26 hospital.   Patient PCP Information Provider PCP Type DO General Discharge Summary by DO at 3/26/2021 12:42 PM Author: DO Service: Cardiology Author Type: Resident Filed: 3/26/2021 12:57 PM Date of Service: 3/26/2021 12:42 PM Status: Attested Editor: DO (Resident) Cosigner: MD at 3/26/2021 1:17 PM  Resident Attestation: I personally saw and examined the patient on rounds with my cariology resident team on the day of the resident's note. Management was discussed with the cardiology resident and I supervised the plan of care. I have reviewed and agree with the key parts of the resident evaluation including:  Subjective information Objective findings on physical exam Impression and plan Gen: appears comfortable, sitting in bed Resp: clear. no wheezes, rhonchi, rales CV: normal rate, regular, no m/r/g Abd: soft, nt/nd Ext: warm, no edema. Pressure ulcer boots on. Pleasant 70-year-old woman who had a history of PVCs, left bundle branch block, and a mild nonischemic cardiomyopathy, came into the hospital following a VT/VF cardiac arrest. Her echocardiogram done while in the hospital showed a preserved ejection fraction. Her cardiac catheterization showed normal coronary arteries. She had implantation of an ICD. Hospital course has been complicated by watershed cerebral infarcts. In addition, she had an episode of C. difficile colitis. She has gradually improved over the course of the past 3 weeks. From a cardiovascular perspective, she is being discharged on carvedilol 25 mg twice a day, lisinopril 10 mg daily, and her home atorvastatin. With regards to her etiology of cardiac arrest, I would be suspicious about the possibility of sarcoidosis. However, we were not able to get a cardiac MR while she was inpatient due to her strokes and inability to consistently follow commands and hold her breath. Would recommend consideration of an outpatient. She is ready to discharge to subacute rehab today. I have spent greater than 30 minutes in discharge planning.  Preferred Name: PATIENT  PCP: DO Primary Cardiologist:  MD Discharging Cardiologist: MD Admission Date: 3/5/2021 Admission Diagnosis: Cardiac arrest  Discharge Date: 03/26/21 Discharge Summary Author:  DO Primary Discharge Diagnosis VT/VF cardiac arrest, s/p therapeutic hypothermia S/p AICD placement 3/16/2021 Secondary Discharge Diagnoses Anoxic brain injury, recovering, with persistent aphasia and dysphagia C. difficile colitis Non-sustained ventricular tachycardia, resolved DETAILS OF HOSPITAL STAY Presenting Problem/History of Present Illness Patient is a 70 y.o. female, with history of nonischemic cardiomyopathy, admitted on 3/5/2021 after out of hospital VT/VF cardiac arrest. She completed therapeutic hypothermia protocol. Cardiac catheterization did not show any significant obstructive coronary disease. TTE showed LVEF 55%. Patient underwent AICD placement on 3/16/2021. Had some recurrent nonsustained ventricular tachycardia afterward, which resolved after increasing her carvedilol doses. Her course was complicated by a C. difficile infection, treated with PO Vancomycin, with significant improvement in diarrhea. She has had gradual neurologic recovery. Neurology felt she had had several watershed infarcts, but felt that she would continue to have a prolonged recovery over the next few months. Had some recovery of language/cognition prior to discharge. Due to her waxing/waning encephalopathy, she did not qualify for inpatient rehab, but will be discharged to subacute rehab. Discharged with tube feeding continued, though she can begin sips with speech therapy supervision. Patient seen and examined at bedside on the day of discharge. She stated that she had no pain, though HPI/ROS still limited due to aphasia. Discussed above information with patient's husband, who understood and was in agreement with the plan.  Problem-Based Hospital Course NEURO Acute metabolic encephalopathy, with gradual recovery -Due to neurologic injury from cardiac arrest. -Neurology consult: concern for anoxic brain injury with watershed infarcts, anticipate very gradual recovery over the coming months. No acute process on imaging. -Patient extubated on 3/11, following some commands. Continuing to regain conversational ability and motor function gradually each day. Has some waxing and waning of mental status, but overall her encephalopathy  continues to improve. -Limit centrally acting/sedating medications -Speech following for language/cognition as well as dysphagia requiring tube feeding. Can begin some sips in addition to tube feeds. -Continue tube feeds via tube per instructions provided on after visit summary INFECTIOUS DISEASE C. Difficile Colitis: -C.Diff Positive 3/18. Continue 125 mg PO Vancomycin Q6H for 10 days (3/18 - 3/27), confirmed with infectious disease -Frequency of diarrhea has decreased significantly, was stable after rectal tube removed 2-3 days prior to discharge Pneumonia, likely due to aspiration, resolved -s/p 5 day course ceftriaxone (3/5 - 3/9 ) -CTA on admission showed significant RUL and RLL consolidation with air bronchograms, as well as some patchy airspace disease in LUL -Had copious tan sputum on suctioning 3/7 - respiratory culture negative CARDIOLOGY Out of hospital cardiac arrest, likely VT/VF -Pt's husband initiated chest compressions x 10 minutes, until police/fire dept arrival, when AED showed a shockable rhythm. Likely VT/VF arrest. -S/p therapeutic hypothermia protocol. -Troponin peaked at 1.09 -3/16 Successful single chamber ICD implantation Nonsustained ventricular tachycardia (NSVT), resolved Chronic left bundle branch block -Has had multiple episodes of NSVT noted on telemetry 3/19 - 3/20 -s/p ICD as above -Increased dose of Carvedilol to 25 mg BID with resolution of NSVT  History of nonischemic cardiomyopathy, LVEF 55% -Echo in 11/2019 demonstrated EF 42% (nadir). -TTE on admission showed recovered EF to 55%, mild concentric LVH, normal RV systolic function, no valvular abnormalities -Was initially started on aspirin/statin due to high suspicion for CAD, but as cardiac cath 3/15 was unremarkable, these medications were discontinued. -3/16 Successful single chamber ICD implantation Hypertension -Blood pressure now improved after restarting home lisinopril and initiating carvedilol -HCTZ discontinued as BP now well controlled on above regimen  RENAL Oliguria, resolved -Pt initially had low urine output since admission, improved to 0.5 cc/kg/hr on 3/9. Continue fluids with free water flushes through tube feeds -Has had normal electrolytes, renal function, and urine output since initial renal recovery. RESPIRATORY Acute hypoxic respiratory failure secondary to cardiac arrest, s/p mechanical ventilation, extubated 3/11 -Patient successfully extubated 3/11, stable respiratory status. Protecting airway well. -Encourage incentive spirometry HEMATOLOGY Acute normocytic anemia, improving -Pt had Hgb drop from baseline around 13-14 at admission to 10.9, now around 10-11. -Has iron saturation of 11%. Normal LDH/bilirubin, ruling out hemolysis. -Started oral iron supplements -Consider outpatient screening for colon cancer ENDOCRINE Osteoporosis - on alendronate at home Discharge Disposition Discharge to skilled nursing facility Active Issues Requiring Follow-up Cardiology -follow-up for AICD placement PCP -post hospital follow-up Test Results Pending at Discharge -none