Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Haemoglobin decreased, Interspinous osteoarthritis, Intervertebral disc degeneration, Klebsiella test positive, Laboratory test abnormal
Clinical narrative: COVID Vaccine Breakthrough Case Pfizer Dose 1 3/12/21 (EN6205) Pfizer Dose 2 4/2/21 (EP7533) COVID Positive 12/3/21  12/3/21: Patient is a 71-year-old female with a past medical history significant for hypertension, hyperlipidemia, OSA, type 2 diabetes, CAD s/p CABG, pacemaker, history of CVA, chronic back pain.  The patient presents to the ED today with complaints of significant weakness.  The patient states over the last few weeks she has been significantly weak, completely losing her ability to ambulate as of yesterday.  The patient's accompanying symptoms include fever, chills, flank pain.  She states her accompanying symptoms began yesterday.  The patient denies any nausea, vomiting, chest pain or shortness of breath. She rates her flank pain 10/10 and describes it as stabbing despite receiving IV pain medications for management.  The patient is vaccinated against COVID-19.  The patient does have known chronic back pain with sciatica to her right leg.  She states however her lower back/flank pain is different from her chronic pain.  The patient denies any tobacco use, illicit drug abuse or alcohol abuse.     Of note, the patient was admitted to the facility on 10/26/2021 discharged on 11/03/2021 the patient was admitted due to confusion and to rule out stroke.  The patient was discharged to a rehabilitation facility for deconditioning.  The patient was discharged from rehabilitation facility on 11/11/2021 with PT/OT in her home.  The patient states she has been progressively weakening ever since then.  The patient admits to having 1 fall since being discharged from the rehab facility.   Upon arrival to ED patient's heart rate 61, respirations 16, pulse ox 97% on room air, blood pressure 130/64. Lumbar spine x-ray reveals severe degenerative changes in the lumbar spine including degenerative disc disease and facet arthropathy; the appearance of the spinous process would be compatible with Bastrop syndrome, degenerative listhesis in the lumbar spine.  Pelvic x-ray reveals no acute fractures. Patient's laboratory findings are significant for glucose 134, BUN 31, hemoglobin 10.1, hematocrit 34.4.  The patient received 1 Lortab, 2 mg IV morphine, 4 mg IV morphine, 750 mg IV Levaquin in ED.  12/13/21: 71-year-old woman who presented worsening generalized weakness, inability to ambulate.  Labs were suggestive of urinary tract infection, COVID-19 PCR was positive and renal function shows signs of dehydration.  She was admitted to the hospitalist service, IV rehydration was initiated, empiric antibiotic therapy for treatment of urinary tract infection was started with urine cultures subsequently yielding Klebsiella pneumoniae.  She was also found to be significantly physically deconditioned and recommended for skilled placement on discharge.  She remained stable from a respiratory perspective anti diabetic criteria for treatment of COVID-19 pneumonia throughout hospital course.  She has been accepted to rehab and his been discharged today in stable medical condition to continue rehabilitation.