Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Paraesthesia, Peripheral motor neuropathy, Platelet count normal, Red blood cell count decreased, Red cell distribution width normal
Clinical narrative: Narrative: Timeline: Moderna Vaccine 1/27/21 and 2/24/21 SX; 4/2/21 Bunionectomy Neurology: 4/6/21 64-yo FEMALE with h/o seborrheic keratosis, abnormal urine test, abnormal mammogram, fatigue, dysthymic disorder, fibroadenoma of the breast, hemolytic anemia, macrocytic anemia, vitamin B12 deficiency, atypical chest pain, pharyngitis, right bunion, allergic rhinitis, congenital hallux valgus, abnormal gait, asthenia, foot wound, postherpetic neuralgia, osteopenia, HSV, colon tubular adenoma, VZV, shellfish allergy, presbyopia, allergic rhinitis, obesity, osteoarthritis, abnormal glucose, dyslipidemia, hyperlipidemia, diabetes mellitus type 2, psychomotor epilepsy NOS (6/3/16 CMS), mixed hyperlipidemia, hypertension, PTSD, hyperlipidemia, essential hypertension, impacted cerumen, acquired absence of uterus, folate deficiency, macrocytosis with request from SURG PODIATRY POST OP for consultation regarding: Patient had foot surgery on 4/2/21 under general anesthesia with a local foot block. She woke up the next day with numbness and tingling and numbness in her hands and it is still going on. c/o hands going numb day after surgery and they are still numb and she can't pick up things with her hands due to abnormal feeling. Foot is sore but pain is manageable, not bearing any weight on operated foot. OBJECTIVE: 2+/4 edema, small bleb distal met head incision, otherwise incision intact. No signs nor symptoms of infection. ER visit4/19/21 The patient is a 64 y/o female with a PMH of pernicious anemia, HLD, possible seizures, and arthritis who presented to medical facility with weakness and numbness. The patient states that she developed numbness and tingling in her hands approximately 3 weeks ago. She reports associated generalized weakness. Patient had base wedge bunionectomy with hardware removal of the left foot on April 2nd, 2021. The patient states this procedure required general anesthesia. Dr. completed an e-consult on 4/6/21 for this issue, he recommended MRI of c-spine. In the ED the patient was found to be COVID-19 positive. She reports weakness/paresthesias as above but is otherwise asymptomatic. Unknown if numbness/tingling/weakness related to COVID dx. Magnesium 1.5. MCV elevated. CT cervical spine showed: Multilevel spondylosis, no significant canalstenosis, severe right foraminal narrowing C4-5 secondary to marked facet hypertrophy. Head CT showed no acute process. Neurology 4/20/21: The patient is a 64 year old female who reports having weakness of the lower extremities since April 9; she has been unable to bear weight. It started in the right leg first, followed by involvement of the left leg. She needs assistance to transfer. For the same duration, she has needles and pins sensations in the toes. She has developed similar symptoms in the hands, and claims she has been unable to feel and hold things. Denies incontinence, but has noticed change in the bowel habits for the same duration of time. No difficulty with chewing, swallowing or vision. History of diabetes for seven years. COVID-19 was negative on March 31, but became positive on April 19. Neurology 4/21/21: Patient was unable to void urine; Foley's catheter was ordered by MOD last evening. MRI Brain and C spine have been without any lesion which could explain patient's symptoms. To rule out the possibility of any structural lesion of Thoracic or Lumbosacral areas, MRIs of these regions with contrast should be obtained as well. As recommended previously, IVIG should be started while the other imaging is being processed. Infectious Disease: 4/21/21 COVId positive w/ clinical concern of Guillain Barre'syndrome. Clinical concern of Guillain Barre'syndrome w/ positive covid-19 -Pt. had natural infection 1/4/21 and also has been vaccinated appropriately w/ 2 doses of Moderna vaccine 1/27 and 4 weeks later. Theoretically, after 90 days positive COVID would be considered a reinfection, especially after negative test 3/31 preop. However this patient is completely asymptomatic from resp standpoint, afebrile, cxr unremarkable and she should have adequate immunity fro mboth natural infection and Vaccine (her igG is checked as well and positive for whatever it is worth). So few possibility we have to consider here 1) Persistent positive/prolong insignificant Shedding leading to current PCR test positive and test done 3/31 was ?false positive. Pt. though does not have underlying immunocompromised condition, appears chronically ill, 45 KG. 2) Asymptomatic reinfection to determine further, we have ordered repeat Roche PCR test (to get CT value which will help determine whether there is replication competent virus infection or just insignificant prolong shedding) and also nasal COVID antigen testing which if positive will be considered new/reinfection. now, re: GBS and covid infection v/s previous vaccine association. 4/22/21 Infectious disease: Reviewed the repeat COVID tests. Has discordant results with different analyzers. COVID Biofire/ROCHE negative. The ROCHE test would have given the cycle threshhold to estimate the viral load had it been positive. My suspicion is that she has a recurrent positive test from her previous infection 3 months ago not a reinfection. Since it's just >90 days since her first positive test, will recommend to keep her on isolation till 4/29 even though this is unlikely a reinfection. -Needs LP to complete work up 4/25/21 Medicine Inpatient: 1. Acute Inflammatory Polyneuropathy, mostly motor in nature possible secondary to either acute covid disease or recent vaccine? -MRI of brain and cervical, thoracic and sacral spine unremarkable. lumbar spine with mild narrowing on MRI. -being treated as if GBS. recieved 3 doses of IgG. Neurology following. -underwent LP on 4/23. ID following. CSF protein high but cell count and diff negative. does not appear to have bacterial menengitis. CSF culture NGTD. 2. Possible neurogenic bladder - patient does report sensation to urinate, so may also have functional component - will leave foley for now given high residual, plan to remove after full PT assessment -MRI of sacral spine unremarkable. 3. COVID-19, asymptomatic, persistent positive test -remains asymptomatic. - receieved both vaccines prior to onset - Roche test negative suggestive of prior infection but not active infection - to remain in quarantine, however, as per ID note through 04/29/2021 4. Depression -continue effexor. -patient seems to have a failure to thrive presentation. very poor po intake of food and fluids. poor physical effort with PT yesterday. now electrolytes dangerously low. -will ask psych to evaluate case on Monday and provide further recs. 5. hypokalemia, hyponatremia and low mag -replace electrolytes -encourage po intake. -will switch IVF to just NS@100/hr -place on remote telemetry and obtain 12 lead EKG. -will follow up on potassium and mag this afternoon after replacement. 6. Weight loss, poor oral intake -unknown amount in unknown amount of time. -dietary consult pending. -has zofran as needed for n/v prn. - CEA minimally elevated, unclear if has had colonoscopy - will need outpatient referral when acute conditions improved, out of isolation - awaiting Ca 125 - thiamine level also pending 7. Weakness, see above -acute cord syndrome ruled out on MRI as of 4/23. -PT to evaluate again this afternoon. -PPD order on 4/23. DVT prophylaxis: heparin sq diet: easy chew diet dispo: PT/OT consult placed today. anticipate will need rehab vs LTC