Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Dyspnoea, Fall, Fatigue, Gait disturbance
Clinical narrative: Discharge Provider: MD Primary Care Provider at Discharge: MD    Admission Date: 6/20/2022 Discharge Date: 6/21/2022  Condition on discharge: Stable   Patient is a 76 y.o. female with PMH of asthma, COPD, GERD, depression, hyperlipidemia, urge urinary incontinence, Etoh use/abuse, who presented to Hospital Emergency Department on 6/21/22 with weakness.               She notes that she had a bad fall the other day, was seen in ER and was sent home. She states "since being home I am not doing well. Im in a lot of pain in my head and back." She notes that her back pain is the mid/lower back and she rates the pain at 8/10. She notes "I have always had a bad back but not in this spot, always lower." She has bruising to the right side of her head. She notes that when she called her doctors office yesterday morning they recommended that she call an ambulance and come into the hospital. She has been able to get up and move around at home using a walker. She notes that she gets dizzy and lightheaded. She states "I can't walk on my own right now and I keep losing my train of thought. I cant stay focused." She notes that she has had trouble focusing since her fall. She notes that the right side of her head where she has the bruising is painful and rates the pain at 7/10. She has been taking Tylenol at home for the pain. She is uncertain as to how she fell but states "every part of my body got hit." She is uncertain if she passed out when she fell. She also notes that her upper abdomen feels tight and sore. She has been having some SOB that she first noticed yesterday and states "I woke up out of my sleep because I couldn't breath." She notes that she coughs all the time but that is not different than normal and she denies wheezing. She denies chest pain or palpitations. She is struggling to remember what day it is. She is feeling tired all the time. She denies fever or chills. She notes "I eat if I think about it but if I dont think about it then I dont." She notes that she lives alone and is unaware of any sick contacts She is vaccinated and boosted against COVID. She has never had COVID before. She notes that she drinks alcohol daily and drinks two bourbon and water. She notes that her last drink was Monday night.               CT head completed in the ER showing no acute intracranial abnormality identified. Stable chronic microvascular ischemic changes and volume loss of the brain. CXR showing nonspecific mild hazy and streaky bilateral lower lung opacities which could represent atelectasis or pneumonia in the proper clinical setting. Redemonstrated background findings of COPD. She was COVID positive  and did require 2L NC when oxygen dropped to 88%. Her labs were essentially normal. Vitals were stable. She was admitted for weakness, confusion and COVID 19. She was admitted for observation.               Mild asymptomatic COVID-19 infection, she is status post for Moderna COVID vaccines.  At this point she was on room air and doing well so no need for Decadron or home oxygen.  She should stay in respiratory isolation for 9 more days.  For her asthma/chronic obstructive pulmonary disease she will continue her home medication Symbicort, Spiriva, albuterol, and Singulair.  Her chest x-ray show no acute changes.              Regarding low back pain and recent falls, she will continue take Tylenol 500-1000 mg q.6 hours p.r.n..  She had x-ray of lumbosacral spine which show no acute fracture, she has diffuse osteopenia, mild dextroconvex curvature of the lumbar spine, and severe degenerative changes at L5-S1.  She was seen by PT, OT and they recommend home health care with home OT and PT.  she should follow-up with the primary care physician in 1 or 2 weeks.              Patient alcohol level was 183. She claims that she drinks II alcoholic drinks at night.  She was seen by medical social worker, she was offer resources for alcohol treatment but she declined.  She does not believe that she has any alcohol problem.              Generalized weakness most likely due to alcohol use, chronic low back pain, and COVID infection.  Per PT and OT she was recommended home OT and PT.  She was evaluated by SLP for cognitive evaluation she did very well.  She was also negative for concussion syndrome.              She was discharged home on June 21, 2022.