Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Fibrin D dimer increased, Full blood count abnormal, Haemoglobin decreased, Head injury, Hypoxia
Clinical narrative: Pfizer Dose 1 4/5/21 (lot NA) Pfizer Dose 2 5/5/21 (lot NA) COVID Positive 1/5/22  1/5/22: Patient is a 72-year-old male with past medical history of coronary artery disease, congestive heart failure, hypertension, hyperlipidemia, COPD, gout, GERD, vitamin-D deficiency, and depression. He receives most of his care at the local facility. History is somewhat limited due to altered mental status. The patient told me that he had 2 syncopal episodes this morning.  Both times, he was trying to sit up in bed.  He felt weak and lightheaded and fell over.  He did hit his head on one occasion.  He denies any other symptoms of numbness, tingling, or focal weakness.  He does admit to feeling weak in general.  He denies any palpitations, chest pain, or shortness of breath.  No fevers, chills, sweats. Review of systems is otherwise negative.  He denies having previous episodes of this, but I did admit him for a similar episode a few weeks ago.  He reports that he lives at local facility independently.  He is unsure of his level of care, but does say that he has neighbors who check on him occasionally.  He denies any alcohol use or illicit drug use.  He does smoke 1 pack of cigarettes per day and has done so for the last 30 years.    Family history is noncontributory.   In the emergency department, his vital signs were normal and stable.  His labs were notable for creatinine of 3.32. It was 1.15 in August of 2021.  He has had several episodes of elevated creatinine since then.  He was recently hospitalized from 12/17/2021 through 12/20/2021 for AKI secondary to urinary retention.  He is unsure of the details of this hospitalization.  It appears that a Foley catheter was initially placed, but later removed.  He was discharged on Flomax.  Patient is unsure if he followed up with Urology as an outpatient.  Today in the ER, Foley catheter was placed once again and it was noted that he had over 1L of urine output fairly quickly and still had a steady stream of output at the time I was called.  His magnesium was also low at 1.5.  Uric acid was high at 11.2. A troponin was drawn and this was found to be 0.06, but he adamantly denied chest pain .  His CBC was notable for WBC of 15.91.  UA was negative for infection.  Chest x-ray was unremarkable as well.  He also had mild normocytic anemia with a hemoglobin of 12.5.  This is chronic.  Due to his falling and syncopal episodes, he received CT C-spine, head, and maxillofacial.  These were all unremarkable.  His D-dimer was 1.10.  V/Q scan has been ordered and is pending.   Apparently, patient's initial complaint to ER personnel was that he was having shortness of breath.  He was placed on supplemental oxygen for a brief period of time.  He was given DuoNebs and Solu-Medrol in the emergency department.  His magnesium was replaced.  He was otherwise admitted for further management.  1/10/22: -As noted patient came in with AKI, altered mental status urinary retention, hypoxia positive for COVID-19 pneumonia.  Foley catheter was placed, renal function improved suspect post renal, dose of Flomax increase Foley will be left in place will have to follow-up with Urology as outpatient for further longitudinal management.  Further pneumonia patient was placed on supplemental oxygen, antibiotics, Decadron, remdesivir inflammatory markers were trended respiratory status improved oxygen requirements gradually weaned down to room air.  Patient clinically well-appearing will discharge home with COVID-19 precautions, will finish course of empiric antibiotics P.R.N. medications co with safe for home program.  Coreg held, hold need BP recheck in 1 week.   Will need longitudinal follow-up with PCP and Urology as noted. Patient endorses understanding and agreement with plan as outlined above.  All ED precautions provided to patient in agreement.