Age: 88.0
Sex: F
Vaccine: VARZOS
Symptoms: Urine ketone body present, Urine leukocyte esterase positive, Vaginal discharge, White blood cell count normal, White blood cells urine positive
Clinical narrative: 88 Y female with Pmhx of Parkinson's disease, atrial fibrillation, hypertension, and diastolic heart failure who presents with generalized weakness and rigors that started yesterday. She was at the shopping mall with her daughter yesterday, and all of a sudden had full body shaking. Daughter, who is a nurse, states that patient's entire body was writhing. Patient also received the shingles vaccine yesterday morning. Daughter drove patient to facility since they were not sure if this was worsening of her parkinson's (possibly from vaccine?) or some other cause. She had blood work and CXR done, unremarkable. She had a urinary tract infection 5 years ago which presented similarly. Her urine was consistent with a UTI. She ws discharged home on Macrobid and took one dose. This morning, patient had significant weakness as well as rigidity of her legs, so an ambulance was called. She complains of dysuria and increased urinary frequency. Also has suprapubic tenderness and some constipation. No fevers but feels hot. No dizziness, nausea or emesis. In the ER, vitals notable for BP in 190's. She states it is from anxiety. BP has improved. Labs are otherwise unremarkable. UA with trace ketones and rare bacteria, some LE and 11 WBCs but unfortunately with significant amount of epi squams. Based on prior cultures, patient was given IV vancomycin in the ER."   1)Weakness; Possibly triggered following recent shingles vaccine. Patient with h/o Prior +UCx growing E Faecium with a lot of resistance. Pt was started on IV Vanco on admission. Urine cx from 6/1/22 Urine cx: Final report: No significant growth. Urine cx from facility from 5/31/22 showed 20,000 CFU/ml mixed flora. No additional workup.  On 6/3/22  dc'd IV Vanco and no indication for further antibiotics at this time. 6/1/22 Blood cx: Preliminary report: No growth at 4 days. PT evaluation on 6/3/22: no PT needs. PCC has arranged for Home Health PT.   2)HfpEF/HTN; stable. Prior TTE from 1/2020 showed EF 50-60%. Patient received maintenance IVF on admission which I have saline locked on 6/2/22. Pt on Metoprolol XL 100 mg daily as outpatient and has had some borderline BP's in house; Metoprolol XL held on 6/3/22; Metoprolol XL dosing decreased to 50 mg PO daily starting on 6/4/22 (Hold for SBP <90).; On Lasix 20 mg PO on Mon and Thursday. Improved BP's following decreasing dose of Toprol XL to 50 mg PO QHS. PCC to arrange for HHRN for BP check.    3)H/o afib; stable. On Apixaban;  Pt on Metoprolol XL 100 mg daily as outpatient and has had some borderline BP's in house; Metoprolol XL held on 6/3/22; Metoprolol XL dosing decreased to 50 mg PO daily starting on 6/4/22. PCC to arrange for HHRN for BP check.      4)H/o Parkinson's disease; on Sinemet.  Pt having more tremors of upper extremities and lower extremity stiffness during hospitalization. Neurology evaluated pt during hospitalization and recommended additional of 0.5 tab of Sinemet QHS.  Pt to follow up with  Neurology on discharge (pt and daughter prefer clinic visit). Appt scheduled  for Fri 6/10/22.    5)Dysuria; may be due to vaginal candidiasis. Pt reports some vaginal discharge and has had yeast infections in past per pt; On 6/3/22,  ID agreed with ordering Fluconazole 150 mg PO x1 which pt received on 6/3/22.    6)RLS: Prior iron panel from 9/2021 showed iron 98, TIBC 319, transferrin % saturation 31 and ferritin 86. Pt prefers to not take bigger dose of gabapentin (300 mg QHS); she prefers to continue gabapentin dosing at 100 mg PO TID. Continue iron supplement. .Neurology recommended addition of 0.5 tab of Sinemet QHS. Melatonin also increased to 6 mg. Pt reporting still not sleeping well/uncomfortable from RLS; I discussed pt with Neurology on  6/5/22 who recommended addition of Gabapentin 200 mg PO QHS (Hold for sedation) and continuing additional of 0.5 tab of Sinemet QHS. Per Neurology, may take 5-7 days to see effects of medication changes and he agreed ok for pt to be dc home with outpt follow-up with Neurology. Appt scheduled with Neurology for Fri 6/10/22.    Primary Procedures:  None   Secondary Procedures: 6/2/22 CT Head 6/2/22 XR Chest     Reason for Hospital Admission (Admitting Diagnosis):  Generalized weakness, increased tremors/rigidity following shingles vaccine