Age: 91.0
Sex: F
Vaccine: COVID19
Symptoms: Alanine aminotransferase increased, Arthralgia, Aspartate aminotransferase increased, Back pain, Bladder catheterisation
Clinical narrative: Moderna Dose 1 4/24/2021 (002C21A) Moderna Dose 2 5/22/21 (022B21A) COVID Positive 1/2/22 COVID Positive 1/6/22 COVID Positive 1/10/22  1/2/22: The patient is a 92-year-old pleasant lady who has past medical history significant for dementia and diabetes. She lives at home with a granddaughter.  She was brought to the emergency room today with fall.  She was found by family on the floor at 2:00 a.m. today morning. Ambulance was called and she was brought to the emergency room.   The patient is not sure exactly what happened.  She is not sure how she fell or how she lost consciousness.  She has small abrasion on her scalp posteriorly.  She has some head back neck and hip pain for which CT scan of the head, cervical spine, lumbar spine and pelvis was done that showed left superior inferior pubic rami sacral fractures. She required two doses of IV fentanyl in the emergency room.  She also about Tdap and Zofran.  When they try to walk her though significant pain and was heart by family that she cannot go back.  On-call orthopedics was contacted who recommended weight-bearing as tolerated and outpatient follow-up if needed.   She also had COVID-19 positive though she does not have too many respiratory symptoms.  She is however not very reliable.  Her labs did show glucose of 223 ALT AST of 80 and 92 and hemoglobin 10.7.  She was subsequently admitted for pain control and deconditioning as she could not ambulate well due to her pain.  The patient states she has some lower back pain but could not give me details.  She denies any complaints to me but she is not reliable.  1/10/22: 92yr old female patient with history of Chronic anemia, dementia, DM-2,HTN, Dyslipidemia, osteoporosis, chronic back pain due to thoracic vertebral fractures, GERD was admitted on 1/2/2022 with complaints of having fallen at home.  Patient was noted to have sustained left superior and inferior pubic rami and sacral fractures.  Patient was admitted to the hospital for adequate pain control and therapy.  She also was noted to be positive for COVID-19 infection.  Patient was placed in isolation.  Orthopedic consultation was obtained from the emergency room and patient was advised to follow up as an outpatient.  Patient continued to work well with physical therapy during the course of hospital stay.  Patient was slowly weaned off of the oxygen and her pain was well controlled.  She completed a course of treatment with dexamethasone which increased her blood sugars during the course of hospital stay.  The Foley catheter was removed.  Patient will complete 1 dose of Levaquin which was prescribed in the hospital on 1/12/2022.  Patient has history of chronic microcytic anemia being followed as an outpatient by Hematology/Oncology.  Patient received 1 unit of PRBC transfusion during the course of hospital stay.  Patient's insulin was adjusted for the blood sugars.  Patient remained stable for discharge to the skilled nursing facility.  Patient's son was updated of the discharge planning.  All questions were answered.