Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Decreased appetite, Enterobacter infection, Fall, Fatigue, General physical health deterioration
Clinical narrative: COVID Vaccine Breakthrough Case  Pfizer Dose 1 3/4/21  (EN6199) Pfizer Dose 2 3/31/21 (EN6205) COVID Positive 9/14/21  9/14/21: Patient is 71-year-old female with past medical history of dementia, CAD s/p stents , GERD, GI bleed, hiatal hernia, renal stone, TIA, migraines, dementia, depression/anxiety, anemia, and chronic pain.  She was brought to the emergency room by her son after syncopal spell showed at home.  Patient has baseline dementia and she was not able to give detailed history.  History was mainly obtained from patient's son. His only son and is in the process of getting power of attorney.  Per patient's son, while she was being bathed sitting, she slumped on her chair, and became unresponsive. Patient appeared gray and pale.  No abnormal body movement oral ring of her eyes.  No urinary incontinence.  She was immediately placed supine position on her bed with improvement in her mental status a few minutes later. No report of chest pain or shortness of breath. d by her son and visiting nurses, she slumped on her chair and became unresponsive.  She was opening her eyes but she was transiently unresponsive.  Per patient's son, her overall status has been declining in the past 2 months with decreased appetite and decreased oral intake.  She is barely able to move without assistance.  Son reported that he noted bruises on her left foot about 2 weeks ago.  He does not recall any fall or trauma in the recent past.  The son has been working with her PMD together to long-term care facility.  His only son and is in the process of securing  power of attorney.  He is also considering possible palliative care/hospice evaluation.  For now he wants her to be on full code.  Patient has history of multiple admissions for anemia. Patient underwent EGD and colonoscopy back in March of 2021. EGD revealed gastritis and fundic gland polyps. Colonoscopy revealed hemorrhoids and sigmoid diverticulosis.  Patient was supposed to follow-up as an outpatient with GI clinic for capsule endoscopy but did not follow through.  Upon initial evaluation at the emergency room, patient was hypotensive with systolic blood pressure in the 60s which responded to IV fluid challenge.  Last blood pressure was 111/66.  She has mild tachycardia but afebrile.  She was maintaining saturation on room air.  Significant lab findings are microcytic hypochromic anemia with hemoglobin of 7.5 gram/deciliter compared to 10.2 back in May of 2021. Lactic acid was at 5.2 which trended down to 3.4 after IV fluid challenge.  Fecal occult blood test is negative. Urinalysis is pending.  At the emergency room, patient received ceftriaxone 1 g IV and bolus of normal saline 2 L.  9/20/21: Patient was admitted and found to be COVID-19 positive.  She was given 2 units of PRBCs for acute on chronic anemia and hemoglobin remained stable around 10.0 during the rest of her hospital stay.  FOBT was negative. She was continued on aspirin for prior cardiac stents greater than 1 year ago.  She remained fairly asymptomatic from a COVID-19 infection other than significant weakness. Respiratory status remained stable.  She was found to have an Enterobacter and Enterococcus urinary tract infection and completed a course of Levaquin.  Patient refused to get out of bed or with therapy daily.  She also refused turns. She also start refusing medications on the 2 days prior to discharge.  Discussed in detail with patient who was alert oriented x3 on multiple occasions and she stated she was just tired.  Ultimately she refused any transfer to a skilled nursing facility.  She was medically stable and will discharge home with her son with Health Assistance.