Age: 82.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Red blood cell count increased, Restless legs syndrome, Sensory loss, Sepsis, Sitting disability
Clinical narrative: 05-31-21 Headache, dizzy, - took Tylenol. 06-01-2021 confusion, vomiting, severely low blood pressure 97/50), admitted to medical center by ambulance. Tested urine in the ER- no signs of urinary tract infection, admitted and given IV fluids for dehydration. 06-02-2021 Moved to ICU as bloodwork showed sepsis. Insertion of infusion device into lower vein, percutaneous approach, medication through IV to control blood pressure, suffered acute respiratory failure with hypoxemia, chronic kidney failure, however, kidneys were still putting out urine. Talk of dialysis was not a concern. 06-03-2021 hallucinating, was contained to bed, still receiving IV fluids. 06-05-2021 medication through IV was helping and was moved out of IC. Platelet count was at 9 or 12, was given a platelet transfusion. Moved out of ICU. Placed in rehab floor in hospital. Was not eating. Signs of aspiration, and dysphagia. Placed on moderately thick med. liquids. Very weak, unable to walk or sit up. Catheter was not removed. Urinary incontinence, Blood work taken daily. While in ICU an X-ray of lungs showed Right lower quadrant completely filled with fluids. Speech therapy started for breathing treatments, was given albuterol. Hospital stay lasted until June 14th. By then was able to walk about 10 feet with the assist of 2 and a wheelchair. Was able to eat however had lost 24 lbs. Admitted to a nursing care facility on June 15th for additional rehab. Still very weak and still getting bloodwork. Blood pressure severely low again and dehydration became another problem. Was given more IV fluids for 3 days. Able to walk with the assist of 2 and wheelchair. Came home on June 21st under the care of daughter to home. 24/7 care required. Unable to transfer on his own and still an assist of 2. Home health began on June 23rd. PT- OT- ST and a visiting nurse 2 times a week. Still silently aspirating and still having fluid in R lower quadrant of lung. Able to toilet with assist of 2 to bedside commode. Blood pressure checked daily. Averaging 96/56. Blood work on July 28th showed RBC count below 8. Was sent for another transfusion. Did great after the transfusion. Within a week was walking on his own. Was able to prepare his meals and walk well. Home health still visiting. Taken off gabapentin per his request. Restless legs were getting worse but was not happy with the side effects of the pill and the chance of a fall due to the weakness. Taken off 24/7 care by August 8th. Sept 27th- swallow test showed aspiration. Sept 28th Bone marrow biopsy given. No issues. Sept 22nd- Started becoming very weak again, loss of feeling in legs and feet. Sever edema of lower extremities by Sept 30th. Visiting nurse stated to just keep them elevated. Oct 15th- became incontinent. Too weak to make it to the toilet. Oct 22nd- Taken by ambulance to ER. Admitted for more tests to see why legs are so weak, all tests were negative. Spine showed severe degeneration. Was sent home Oct 29th.   Nov 7th- had surgery on thoracic area of spine to see if it would help him walk. Sent then to rehab after for more therapy.  Nov 22nd back home. Still nothing has changed. Still very weak and unable to walk without assist of 1. He transfers by wheelchair. Not incontinent anymore. Able to transfer himself from wheelchair to toilet. Still receiving home health 2x a week from PT and nurse. Bloodwork still shows his RBC low. (8.4)  Will need another transfusion soon. He is always very tired. He is anemic but not sure how or where it is coming from. Jan 5th- endoscopy performed- showed no lesions that would result in the blood issues. Sever edema still in lower extremities. Still very tired and weak. Still confined to the wheelchair to transport around his home. 3 more weeks of home health.