Age: 90.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Muscle spasms, Musculoskeletal discomfort, Pain, Pain in extremity, Pleural effusion
Clinical narrative: Dr.  note-  H&P: chief complaint: back pain  HPI: White female who presents with low back pain. Patient states that she did have a ground level fall several weeks ago and landed on her left side and had bruising to the left side of her chest wall but states this resolved and is unsure the low back pain is because of the fall. Patient went to a local urgent care because of a fever T-max 102 F on 11/20/2021 and was also complaining of right flank pain with some mild radiation down her legs at that time. She also was complaining of urinary hesitancy and frequency some incontinence throughout the day. The patient was seen and evaluated in the ED and had essentially normal CMP, UA, lactic acid, noted to have a slightly elevated WBC at 14.7 and did have a normal lipase. Patient underwent a CT of the abdomen and pelvis with IV contrast which demonstrated no acute findings. The patient was discharged with musculoskeletal low back pain and prescribed Flexeril 5mg which she states she is taking least 3 doses with no improvement of her discomfort. She has taking Tylenol with minimal improvement of her discomfort. She notices increased discomfort of her lower back with range of motion. She currently denies any pain radiating into the legs. Patient relates that she has had significant worsening of her pain with any movement, muscle spasms and fatigue since receiving her COVID-19 vaccination booster. Denies fever, chills, cough, sob, chest pain, nausea, vomiting, abdominal pain, diarrhea, urinary symptoms, other bowel or bladder complaints, saddle paresthesia or weakness of the lower extremities. ED evaluation including CT of the lumbar spine was unremarkable for acute pathology. However, patient continues to have significant ambulatory dysfunction and pain with movement. She will be admitted for further evaluation and treatment and rehab services consultation.  Diagnoses: ambulatory dysfunction, back pain, falls, diabetes mellitus type 2, CAD   PA-C note-   ED: chief complaint: lower back pain  HPI: 90 y.o. female who presents to the ED complaining of continued low back pain. Patient states that she did have a ground level fall several weeks ago and landed on her left side and had bruising to the left side of her chest wall but states this resolved and is unsure the low back pain is because of the fall. Patient went to a local urgent care because of a fever T-max 102 F on 11/20/2021 and was also complaining of right flank pain with some mild radiation down her legs at that time. She also was complaining of urinary hesitancy and frequency some incontinence throughout the day. The patient was seen and evaluated in the ED and had essentially normal CMP, UA, lactic acid, noted to have a slightly elevated WBC at 14.7 and did have a normal lipase. Patient underwent a CT of the abdomen and pelvis with IV contrast which demonstrated no acute findings. The patient was discharged with musculoskeletal low back pain and prescribed Flexeril 5mg which she states she is taking least 3 doses with no improvement of her discomfort. She has taking Tylenol with minimal improvement of her discomfort. She notices increased discomfort of her lower back with range of motion. She currently denies any pain radiating into the legs. She has not yet followed up with her primary care physician.   There are notes in the computer apparently from a nurse at the patient?s PCP?s office which demonstrates that the patient?s daughter is concerned because the patient continued have a fever today of 101 F and also continues low back pain. Is initially thought that the fever that she presented with a couple days ago was likely due to her recently receiving COVID booster on 11/17/2021. They were apparently advised to return to the ED if there is any new or worsening symptoms and the daughter was concerned about possibility of a UTI or still due to receiving the COVID booster.   RN note: EMS time out complete. Pt had a fall approx 4 weeks ago. Started with lower back pain on the 17th. States the pain is bilateral but shoots down her left leg. No other known injury noted.