Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Inflammatory marker test, Joint injury, Magnetic resonance imaging head normal, Mental status changes, Pneumonia
Clinical narrative: Pfizer Dose 1 4/1/21 (EN6198) Pfizer Dose 2 4/23/21 (EW0153) COVID Positive 1/2/22  1/2/22: Patient is a pleasant 67-year-old male with past medical history of intellectual/cognitive impairment comes in with chief complaint of mechanical fall.  Patient is not very good historian history is primarily obtained from chart review. Patient with cognitive impairment at baseline reportedly EMS was called as patient had ground level fall ambulating to restroom, patient fell forward on his knees no loss of consciousness.  Patient endorse bilateral knee and hip pain in low back pain, ordered lead did strike his head.  His caretakers sister-in-law who lives with him reports frequent falls at baseline usually able to assist back to chair or sitting position however after this current fall patient was unable to follow directions and was confuse not understanding what was being asked of him which is a new finding.  Patient usually stays at home and only leaves the house for essential visits.  Was going to therapy at home could ambulate and of block.  Stationary bike otherwise sedentary.  In the emergency department blood work and imaging were obtained.  Chem panel, blood gases, tox screening, hemogram, UA without acute derangement.  In addition CT head, C-spine repeating negative for acute derangement.  plain film imaging of femur pelvis on lumbar spine without acute derangement. EKG reportedly negative.  Chest x-ray concerning for possible pneumonia.  Patient received Rocephin emergency department request was made to admit to medical service for further treatment evaluation.  At bedside patient is lying comfortably in bed denies any lightheadedness, dizziness, vision change, chills, fever, nausea, vomiting, diarrhea, chest pain, palpitations, abdominal pain, paresthesia, swelling of extremities, pain or discomfort of joint her extremities.  Reports compliance with all medications provided on home unclear on recent change.  Unclear on sick contact, unclear on COVID-19 vaccination status.  Denies tobacco, alcohol, marijuana/recreational drug use. Attempted to obtain family history a however patient is unable to provide further insite.  1/5/22: Mechanical fall  History of recurrent falls Community-acquired pneumonia COVID-19 positive  - imaging studies as noted.  MRI negative, for CVA. Further imaging no acute deformity or derangement.Therapy home health as outpatient. falls may be mechanical versus infectious etiology from COVID.  - as per chest x-ray, no leukocytosis no respiratory distress, low-grade temps.  Empirically treat with Rocephin/doxycycline   Blood cultures remain negative for 48 hours.  Vitamin-C, D, zinc  Doxycycline. these can be continued on dispo for course..  Inflammatory markers reviewed currently does not qualify for remdesivir, dexamethasone. -  patient did not require oxygen during hospitalization. However  patient did have falls at home and  mental status changed from baseline according to family.  Family strongly requested O2 walk prior to discharge for this purpose.   I felt because of this it wasn't unreasonable to get an O2 walk prior to disposition even if patient was not requiring supplemental oxygen-- O2 walk orders placed.  Respiratory therapy  provider called me and refused to do oxygen for home going walk even after multiple verbal request were made, along with formal order in Cerner-- order was discontinued unilaterally without physician consent even after unique circumstances were conveyed.  In addition RT provider stated that she would convey to nursing to do oxygen walk if needed, however I spoke to patient's floor nurse who notified me that this was never done and no O2 walk for home going was done as stipulated in discharge orders prior to patient leaving facility.  Rule out CVA-  - MRI is negative, suspect mechanical/metabolic/ infectious related.  Cognitive impairment  - baseline.  Family member/ sister-in-law primary caregiver.     All ED   And RTC precautions were provided to patient, in writing patient endorse understanding.  Further precautions provided to patient's family along with quarantined