Age: 82.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19, COVID19
Symptoms: Body temperature increased, COVID-19, Chest X-ray normal, Computerised tomogram head normal, Computerised tomogram spine
Clinical narrative: 83-year-old female who presents the emergency room tonight for evaluation after a fall.  Patient lives at home with her daughter.  She sustained a fall this evening.  I do not believe there was any loss of consciousness.  The patient has had CT of her head, C-spine, T-spine, L-spine all of which do not show any acute fractures.  She does have severe degenerative disc disease in her lumbar spine.  Patient is noted to be mildly hypoxic on pulse ox in the emergency room.  And also EMS reported that she had a temperature of a 101°.  She has not been febrile in the emergency room.  The patient's daughter reports having COVID approximately 6 weeks ago.  She was diagnosed on 08/30/2021. The patient herself had an initial to vaccinations in January in February this year and the daughter reports that she had a booster approximately 1 week ago.  The patient has not really had any cough.  She may have had some mild shortness of breath.  No diarrhea reported.  On blood gas in the emergency room the patient has a PO2 of 55.  The patient also has a history of COPD and according to the daughter has been out of her Breo Ellipta for approximately 2 weeks.  Patient is not normally on oxygen at home.  Chest x-ray in the emergency room tonight does not look particularly bad.  It actually appears unchanged from her previous chest x-rays.  I have been asked to admit the patient due to her COVID positivity and mild hypoxia.  The daughter does report that the patient has had a mild cough which she thinks has been present for a couple of weeks. Review of Systems  Constitutional:  [Patient denies fever, chills, sweats, and weight changes.] Eyes:  [Patient denies any visual symptoms] ENT:  [No difficulties with hearing. No symptoms of rhinitis or sore throat.] Cardiovascular:  [Patient denies any chest pain, palpitations, orthopnea, or PND.] Pulmonary:  As in HPI Gastrointestinal:  [No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia, or melena.] GU:  [No urinary hesitancy or dribbling. No nocturia or urinary frequency. No abnormal urethral discharge.] Musculoskeletal:  [No myalgias or arthralgias. No hot, swollen joints.] Neurologic:  [No headaches, no seizures. Patient denies numbness, tingling, or weakness on either side of the body. There are no visual symptoms.] Psychiatric: [Patient denies problems with mood disturbance or anxiety.] Endocrine: [No excessive urination or excessive thirst noted. No heat or cold intolerance. No weight gain or changes in skin or hair.] Dermatologic:  [Patient denies any rashes or skin changes.] Physical Exam  Vitals & Measurements  T: 99.2  °F (Oral)  HR: 81(Peripheral)  RR: 20  BP: 165/83  SpO2: 92%  WT: 90 kg   VITAL SIGN               LAST CHARTED          MINIMUM                 MAXIMUM            Blood Pressure        165/83 (10/10 23:00)   165/83 (10/10 23:00)    173/84 (10/10 22:45) Heart Rate                81      (10/10 23:00)      81     (10/10 23:00)     110  (10/10 22:45) Respirations             20      (10/10 22:45)      20     (10/10 22:45)     20     (10/10 22:45) Temperature            99.2    (10/10 22:45)     99.2   (10/10 22:45)     99.2  (10/10 22:45) SpO2                         92      (10/10 23:00)      92     (10/10 23:00)      92    (10/10 23:00) Weight                      90     (10/10 22:45)      90     (10/10 22:45)     90     (10/10 22:45) Admitted 0/11/2021.  Currently in COVID Stepdown unit.