Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Cerebral hypoperfusion, Computerised tomogram head abnormal, Haemoglobin decreased, Humerus fracture, Joint range of motion decreased
Clinical narrative: ***Possible Breakthrough Case*** Per H & P    HISTORY OF PRESENT ILLNESS:  The patient is a 71-year-old female who was sent from my office because of transient episode of having ataxia, nausea and vomiting.  She was referred to the ER to rule out any stroke.  She had CT angiogram of the head and neck as well as CT of the head, with and without contrast, which showed nonspecific mildly delayed perfusion within the left parieto-occipital lobe.  The patient is completely asymptomatic.  She does not remember what had happened in the office.  PAST MEDICAL HISTORY:  Significant for history of diabetes and hypertension.  ALLERGIES:  No known drug allergies.  PAST SURGICAL HISTORY:  She had excision of right foot, incision and drainage of foot and colonoscopy was done.  MEDICATIONS:  See the list.  SOCIAL HISTORY:  No history of smoking, drug abuse or alcohol abuse.  REVIEW OF SYSTEMS:  The patient at this moment, when I saw her in the hospital, is totally asymptomatic, denies having any fever, chills, rigors, headache, lightheadedness, blurry vision, ringing in the ears, chest pain, shortness of breath, nausea, vomiting, diarrhea, abdominal pain, tingling, numbness or weakness.  PHYSICAL EXAMINATION: VITAL SIGNS:  Temperature is found to be 98.2, pulse 78, blood pressure 132/63 mmHg and O2 sat 98% on room air. HEENT:  No pallor, cyanosis or jaundice. NECK:  No JVD, no thyromegaly and no lymphadenopathy. HEART:  S1 and S2 are present. LUNGS:  Bilateral breath sounds. ABDOMEN:  Soft and nontender.  Bowel sounds are present. EXTREMITIES:  There is no edema and no calf tenderness. NEUROLOGIC:  The patient is completely awake, alert and oriented x 3.  No focal neurological deficits.  The only thing she has is she cannot move right arm completely above the head because she had recent fracture of the humerus for which she had sling, which was recently removed.  The patient had tested positive 1 month ago with COVID, and she had been remaining asymptomatic.  The rapid test had come positive, but 1 week ago, she had the test, which was negative.  ID has already seen, and the thought process was that she has asymptomatic particles remaining, but the patient is not interactive, and no isolation precautions were needed.  LABORATORY DATA:  All lab work was reviewed.  DIAGNOSTIC DATA:  Test results were reviewed.  DIAGNOSTIC IMPRESSION: 1.  Mental status changes, which have completely resolved. 2.  Nausea and vomiting, which has resolved. 3.  History of right shoulder fracture some time ago, status post sling. 4.  Diabetes. 5.  Hypertension. 6.  Low hemoglobin. 7.  Pulmonary nodule.  PLAN:  So, at this point, we will continue supportive care for the patient.  Home medications are to be continued.  ID consultation is there for COVID-positive status.  Neurology consultation has already been placed, waiting for them.  I will put cardiology consultation to find out any cardiac source of the above symptoms.  We will check an echocardiogram for the heart.  The patient is walking very comfortably.  She does not need any physical therapy because she is not unstable at this point.  Again, I will wait for all consultants' input and then make discharge plans for the patient.  Sliding-scale insulin is to be continued.  Home medications are to be continued.