Age: 71.0
Sex: F
Vaccine: COVID19-2
Symptoms: Muscle spasms, Myoclonus, Nausea, Neurological examination normal, Orthostatic hypotension
Clinical narrative: Pfizer-BioNTech COVID-19 Vaccine, Bivalent EUA 1/13/23-2:34 pm ER arrival via ambulance for weakness, worsening of chronic tremors, confusion concerns. Per EMS report Patient's PCA, home health nurse, and Patient's daughter report Patient confused lately, concern if she has been taking more medication than prescribed. Daughter reported patient has broken into medication manager devices previously multiple times for unknown reasons. Today, PCA notified daughter that patient had full body spasm several times a minute and she was also somewhat confused. 911 was called. ER chief complaint-tremors. Started 1/13/23 morning but episodes 2-3 weeks ago. Feeling forgetful over past couple of weeks. Weakness complaints, concerned going to fall. Also positive for nausea, without vomiting. Positive for lightheadedness, positive for shortness of breath, positive for chest pain, positive for urinary urgency, and blurred vision last 2 weeks. Denies recent falls. Exam alert, not oriented to time states "2022" and month "February". Attempted to get patient up by she was too weak to stand with assistance. No exam mention of tremors. EKG, labs, UA done. Hgb stable 9.6, sodium 132, COVID-19 PCR negative, UA negative for infection, acetaminophen level low, troponin normal. EKG-no acute concerns per chart review. Diagnoses-Weakness and myoclonic jerking-Admitted to hospital. 1/13/23-Hospitalist visit-Diagnoses Weakness/Confusion Plan-Physical Therapy evaluation. Regarding confusion Hospitalist note neuro exam "grossly intact-mentation, motor, speech" 1/14/23-Nursing note-Slight muscle jerking. Patient A&Ox3 but confused, thinking daughter there, rambling to self. 05:28 am BP low 89/57 physician paged and 250 ml bolus given 08:14 am 100/52 BP, oxygen 85% on room air, placed on 2L nasal cannula 92% saturation 1/14/23Hospitalist note-Patient reported cough. CXR ordered. Diagnosis-COPD exacerbation-started on prednisone, oxygen to maintain saturations 88%. 1/15/23-Physical Therapy evaluation-Patient very fatigued, required assistance of 1, advised post acute rehab facility due to fall risk. Patient had BP drop 91/57 to 72/41 then back to 97/51 with no dizziness complaints. Hospitalist note-Diagnosis-Toxic medication induced encephalopathy-resolved. Polypharmacy diagnosis, but no new medication changes noted. Diagnosis-Orthostatic hypotension-felt secondary to polypharmacy. Plan knee high stockings. 1/16/23-Physical therapy evaluation-Patient reported feeling much improved, ambulated 300+ feet with rolling walker, standby assist. Advised Patient to benefit from home health physical therapy for discharge plan at this time to work on balance. Occupational Therapy evaluation-Patient was reported "has functional cognition for basics of mental function-direction following, attention span, safety awareness intact". SLUMS score 24 (previous score 20, 10/27/2022) 1/16/23-Patient discharged home with home health care orders for COPD exacerbation at 7 pm. Vitals earlier in day 98.0F, pulse 75, resp 18, BP 115/76, oxygen 96% on room air. Was not discharged with oxygen.  Discharge diagnosis-Acute toxic encephalopathy from medication side effects and polypharmacy. Weakness/confusion-nothing acute identified.   Discharge diagnosis -COPD exacerbation-Discharged on continued prednisone, off oxygen, continued on previous inhalers/medications. Discharge diagnosis-Orthostatic hypotension-Knee high stockings advised. 01/17/23-Home care nurse reported Patient declining PT/OT services, desires RN services. Home health nurse set up patient medications the morning of 1/17/23. 01/18/23-Home visit with Provider. Documentation not fully complete at this time. Appears gabapentin dose was decreased from 200 mg twice daily to 100 mg twice daily with plan to wean and discontinue. New home care order for Physical Therapy for COPD exacerbation placed.  01/19/23-Home care physical therapist noted Patient declined home 1/19/23 at home physical therapy visit, Patient desires to reschedule for 1/23/23 date.