Age: 72.0
Sex: M
Vaccine: PPV
Symptoms: Computerised tomogram head normal, Confusional state, Delirium, Dyspnoea, Haemoglobin decreased
Clinical narrative: The evening of 3-29 the staff of facility assisted living where patient lives reported to sister that patient had a high fever. Morning of 3-30 they reported confusion, nausea, vomiting and headache. Patient had px on 3-28 and had no symptoms. Had DRE, bilateral ear irrigation and PNEUMOVAX. Sister was contacted again by facility and she transported patient to the ER on 3-30 at their request. He had lab and x-ray tests, IV fluids and was admitted to the hospital. The patient was admitted from the ER on 3/30/19 with SIRS, had IV fluids in the ER and vital signs stable. WBC elevated 20 and Lactic level normal at this time. He had some nausea/emesis. He had blood cultures drawn x 2. Chest Xray, CT head and UA were all normal. He was provided prophylactic antibiotics. He was kept on IV fluids due to the nausea/emesis. There was report of SOB and he was continued on his inhalers, CXR was negative. The next morning, WBC still elevated at 20. He had noted redness and warmth of the left upper arm where pneumonia shot had been provided 3 days prior to admission. This area was very tender to touch and his arm hurt with movement. He had clear liquid diet as tolerated. 4/1/19 WBC slowly improving to 18 and redness of the left upper arm still noted and tender, this had extended some since admission. The patient continued with intermittent headaches also throughout his stay. Blood culture prelim was negative as was the strep culture. PT/OT were initiated to assist the patient with strengthening and balance. (He has limited vision) and so in this environment has thrown him off. Diet was increased since no further nausea/ emesis. 4/2/19. WBC back to normal so stopped the Vancomycin and ROCEPHIN IV. Changed to Cefdinir 300 mg po bid for another 8 days. His redness and warmth of the left upper arm continued to recede. PT/OT continued to work with the patient. His intake also improved. He continued to have intermittent headaches and reviewed his chart and those are noted by Dr. in her notes also. So most likely no change. Head CT done at time of admission showed no acute changes. 4/3/19 The labs in AM of 4/3/19 showed normal WBC, CRP down to 7 and BMP is fine. He will be ready for discharge home to the facility which is an assisted living. He will continue with PT/OT at home for strengthening. The patient is a 72-year-old male here today for followup of a recent hospitalization. I had seen him for his annual physical on the 28th of March. He did get his immunizations updated. He got his pneumococcal polysaccharide vaccine and developed redness of the left upper arm and then developed fever is some mild delirium and confusion. He presented to the emergency room and he was found to have an elevated white count was 20,900, hemoglobin 11.5 and a platelet count of 202,000. His blood sugar, electrolytes and kidney function were unremarkable. He also had a fever. He was hospitalized and slowly over time, improved. He said he has been discharged back to the facility and he said things are back to normal. When he and his physical, we did do screening lipids, but he does not want to treat that.