Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Blood culture negative, Blood urea normal, Chest X-ray abnormal, Confusional state, Cough
Clinical narrative: Late entry for patient seen this morning. S: Nurse informed me yesterday that patient returned from the Hospital & the diagnosis was Pneumonia/UTI/Sepsis. They want her on Augmentin for 5 d which was started. Patient was put on Zosyn, Doxycycline & Famotidine, DuoNeb & also on Lovenox in the hospital. CXR done in the hospital showed Rt Perihilar & basilar airspace disease. Looked through Hospital records & patient did not have an elevated WBC (5.8 on 7/8/22 & 3.46 on 7/8/22). CMP showed Albumin of 3.3, BUN- 18  & Cr- 0.8, Troponin was normal, COVID Antigen was negative, Blood Cultures were negative. Urine showed Leucocyte esterase positive & Nitrite positive & WBC- 50-100, Bacteria 4+. Urine culture showed mixed growth indicating Contamination. O/E T- 97, PR- 86, RR- 18, BP- 138/74, O2 sat -98% on RA. Patient awake & alert & sitting in her WC, Telling staff she does not want to drink any more water. Chest: AE equal bilaterally, Heart- RRR, Abdomen - soft & non tender & Bowel sounds present. A/P Post hospitalization for altered mental status- Doubt this is a Pneumonia/Sepsis or a UTI. Think this is an adverse Reaction to the Moderna Vaccine. She got the Moderna vaccine the day before she was sent to the hospital. Patient had a mild fever & was fatigued & tired & wanted to sleep the day she was sent to the Hospital. Per admitting doctor's notes she was having a cough for a few days before she was admitted & that information he got from the staff who was with her. No Nurse reported a cough prior to her admission. Also noted by admitting doctor that she had presented with several days of generalized weakness & change in Mental status but she was only lethargic the morning that she was sent to the hospital. H/o Bladder biopsy shows Cystitis Glandularis Cystica with Florid Acute & Chronic Follicular Cystitis- will start on Trimethoprim per Dr. recommendations next week. Elevated BUN in the past but her BUN has been normal- staff to encourage her to drink water. Weakness, lethargy. Subjective/History of Present Illness. (Late entry) patient's DSP alerted on 7/8 @ 1150 that she was extremely weak on transferring. The LVN notified the DRN who assessed her @ 1200 and found her to be lethargic and confused but able to answer questions. Exam and VS otherwise unremarkable except for a HR of 138 (BP 140/70).  She informed me and was directed to transfer her to alternate hospital via Ambulance service. The ER was notified by the DRN @ 12:28 and the Hospital Liaison followed up at 1409 and was told that she was admitted with a diagnosis on Pneumonia and was being treated with IV Zosyn and doxycycline. Client has had an elevated BUN beginning last November culminating in an admission to the Infirmary in May for IVF (max BUN 33 on 5/17/22). Her staff has been encouraging her to drink more fluids during the day since then and her most recent BUN was 18 on 7/7. She underwent a cystoscopy and biopsy by Dr. on 6/23 for urinary retention and was treated briefly with cefuroxime, Pyridium, and Florastor afterward for post-procedure prophylaxis. At her f/u appt. with him on 6/30 he recommended prophylaxis with trimethoprim nightly x 90 days at which time he would follow up. She had the Moderna COVID-19 booster on 7/7 @ 1644 with no adverse reactions noted, but she did have a BP of 90/50 @ 0739 on 7/8. Repeat BPs were 104/48 and 113/48 @ 0755. At 0855 it had come up to 130/61. Review of Systems: No fever, nausea, or vomiting. Her last meal refusal was on 6/26 at lunch, but she accepted a supplement. No change in bowel or bladder habits noted, and she was being followed closely for all of the above issues. No recent fall or head injury and no c/o HA or abdominal pain.  No hematuria or abdominal distention. No cough or congestion. As previously noted by Dr., client was sent to the ER on 7/8 with marked generalized weakness and AMS. HX. was notable for the fact that she had received the Moderna COVID-19 booster the day before. Indeed, Her workup at the ER was negative for either UTI or Pneumonia but she was started on antibiotics in the hospital and discharged back to us on Augmentin. After she had multiple loose stools in a day this was discontinued and for the past two days she has had one large soft formed stool daily (and continues of Florastor). Her staff states that she is back to her baseline, typically sleeping all morning and up in the afternoon. The weakness has resolved and there have been no new complaints.