Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Activated partial thromboplastin time shortened, Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase normal, Bacterial test negative
Clinical narrative: Patient came home and went to sleep. He ended up sleeping for 3 days. he only got out of bed to get something to drink & use the restroom. I forced him to get out of bed on 6/19/2021. It took him 45 minutes to get dressed with help after a bath. He was very disoriented. On 6/20/2021, he seemed mor oriented & felt better. I attributed it to 3 days without eating anf finally getting some nutrition in his body. On 6/21/22, he tried cutting the grass with our zero turn mower and fell twice trying to get on the mower (he is very familiar with mower: normally services it and cuts our grass weekly in the summer). Early on the morning of 6/22/21 (05:00), he awakened & stumbled on the way to the bathroom, nearly falling. After using the bathroom, he tried to go to the kitchen to get a drink of water. He could not find the bedroom door or the light switch (we have lived in this house for over 10 years). I told him not to move for fear he would fall. When I turned on the bedroom light, he had closed the bedroom door & was standing in front of it. He was very confused & disoriented. I opened the door for him. He made it to the kitchen but when he got back to the bedroom, he fell & hit his head. I decided it was time for me to just get up and watch him. I put him to bed & dressed his superficial head wounds. I then went about my morning, getting ready for work. He seemed to do better once I had him drink a protein shake. I went on to work. He made it to an ophthalmologist appointment that morning. Around 10:30 am, I received a phone call from the ophthalmologist. Patient was talking about a dog in the office that was not there! Since we live in a small town, office staff drove patient to the local emergency department for evaluation. I met him there, Lab work (which included CBC, CMP, ESR, urinalysis & CSF studies) were pretty much normal with a few abnormalities, but nothing to explain his confusion, loss of equilibrium, and hallucinations. He also had a CT of head w/o contrast, which was normal and MRI of head w/o contrast (normal). When the CSF studies were normal, he had a CT of chest/abdomen/pelvis w/o contrast (normal). Even though he has been doing better, since receiving his second Covid vaccine 6/15/21, I have noticed he is more forgetful and does not remember when we have had certain conversations. Obviously, he will not be receiving any booster vaccines. Lab Results of 6/22/21: CBC: WBC 5.1, H/H 19.7/40.7, PLTS 185, MCV 84, MCH 28.6, MCHC 34, EDW 14.7; DIFFERENTIAL: Neuto 44, Bands 22, Lymph, 32 and Eosin 2. CMP: Na 136; K 4.9, Cl 103, Bicarb 25, BUN 33, Creat 1.6, glucose 105; anion gap 12.9; Osmolality 279.6, albumin 2.6, Globulin 4.6, Alk Phos 86, Asp Amiontansferase 23, ALT, 31, Bili 0.5, Ca 8.7; Lactic acid 1.5; Procalcitonin 0.165; PT/PTT 14.7/30.2; INR 1.08; U/A: Color dark brown; Sp grav 1.030, pH 6.5, protein 14, glucose negative, ketones trace, Urobilinogen 1.0, RBC 0.3, WBC 0.3, leuk esterase negative, nitrite positive, epithelial cells occasional, bacteria negative, casts negative; CSF: glucose 54, protein 70, WBC none, RBC 2800