Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Cerebral atrophy, Cerebral calcification, Cerebral small vessel ischaemic disease, Chest X-ray abnormal, Computerised tomogram head abnormal
Clinical narrative: 1/24/2022   Chief Complaint:  Fall   Source of Information:  Patient and Available medical record   History of Present Illness:  This is a 73y.o. male with a past medical history significant for atrial fibrillation, coronary artery disease, diabetes type 2, dyslipidemia, GERD, gout, hypertension, myocardial infarction, peripheral artery disease, right bundle branch block.  He presents for evaluation of a fall at home.  EMS reports that the patient fell out of bed and is currently on a blood thinner Xarelto.  Patient adamantly stating that he did not fall out of bed on his own, rather stating that he was pulled out of bed by his roommate.  He states that he asked his room at the pulmonary bed because he was feeling hypoglycemic stating that he was feeling rather lethargic.  He states that his roommate subsequently pulled him out of bed and he was lowered to the ground, stating that it was not truly a fall.  He states that he did land on his right hip however the right hip pain that he originally experienced was chronic in nature.  EMS reports his blood sugar was 33 on arrival and was given dextrose with improvement to 129.  Patient reports that he has had issues with regards to his diabetic management over the previous months.  He states that his prior hemoglobin A1c was elevated however he could not remember the value.  He states that as of recently have been titrating his insulin regimen along with his oral medication regimen and has had intermittent episodes of hypoglycemia lately.  However he cannot remember his current regimen and states that he is at times noncompliant with certain medications particularly insulin regimens however he states that he does take his oral diabetic regimen routinely.  He denies any loss of consciousness, hitting his head, or neck injury.  States that he fell on his right side.  States that he does have some pain in his right hip but has since resolved.  Patient states that his weakness was improved shortly after receiving the dextrose infusion.  Currently denies any fevers, chills, headache, change in vision, nausea, vomiting, diarrhea.  Currently denying abdominal pain, chest pain, shortness of breath, lightheadedness, dizziness, leg swelling.  Patient does report that during the event he did urinate on himself because he was too weak to negative bathroom.  He does note that his 2 brothers were recently diagnosed with Covid however he states that he was not in contact with them over the preceding month.  He states that his sister has similar upper respiratory symptoms to which he has had.  He states that his primary complaint is upper respiratory congestion along with cough.  He states that the symptoms has been going on for approximately 1 to 2 weeks.  Not primarily noting extensive cough however he does state that intermittently he will have 1.  Does not know what his sister was diagnosed with but believes that he has the same ailment as her.     In the ED, Vitals on arrival of T 97.5°F, BP 108/74, HR 100, RR 14, SpO2 96% on room air  Labs remarkable for white blood cell count 19.4, hemoglobin 14.1, platelets 222.  INR 2.2.  Sodium 138, potassium 4.9 hemolyzed, chloride 106, bicarb 20, BUN 15, calcium 9.  Creatinine 0.78.  Covid, flu, RSV swab pending. Imaging: CT head negative for acute intracranial process.  Nonspecific white matter changes likely secondary to chronic small vessel ischemic disease.  CT cervical spine no evidence of cervical spine fracture.  Mild degenerative disc disease most pronounced at C5-6 and C6-7 with at least mild spinal canal stenosis.  Chest x-ray showing hazy increased interstitial opacities throughout the left lung concerning for infectious process.  X-ray of right hip no fracture or dislocation.  Mild bilateral hip osteoarthritis.  Lumbar spondylosis. Patient received ceftriaxone and azithromycin for community-acquired pneumonia.