Age: 75.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Chills, Chronic obstructive pulmonary disease, Condition aggravated, Dysphagia, Gait disturbance
Clinical narrative: Pfizer vaccine given on 3/12/2021, 4/6/2021  CHIEF COMPLAINT Generalized weakness Worsening lower back pain.   HISTORY OF PRESENT ILLNESS Patient is a 76 y.o. male with medical history significant for, -- COVID infection (positive 10/29, received Casirivimab/imdevimab infusion on 11/1/21),  -- tobacco use,  -- anemia,  -- CAD,  -- dilated cardiomyopathy/ ischemic cardiomyopathy and h/o MI, s/p ICD placement,  -- CKD stage 3,  -- COPD,  --Type 2 Diabetes  --hx of RCC s/p left partial nephrectomy.    Patient presented to Hospital earlier yesterday for the evaluation of acute on chronic worsening of his low back pain and associated weakness for the past 2 weeks.  He stated he has been  Additional information for Item 18:  CHIEF COMPLAINT Generalized weakness Worsening lower back pain.   HISTORY OF PRESENT ILLNESS Patient is a 76 y.o. male with medical history significant for, -- COVID infection (positive 10/29, received Casirivimab/imdevimab infusion on 11/1/21),  -- tobacco use,  -- anemia,  -- CAD,  -- dilated cardiomyopathy/ ischemic cardiomyopathy and h/o MI, s/p ICD placement,  -- CKD stage 3,  -- COPD,  --Type 2 Diabetes  --hx of RCC s/p left partial nephrectomy.    Patient  presented to Hospital earlier yesterday for the evaluation of acute on chronic worsening of his low back pain and associated weakness for the past 2 weeks.  He stated he has been having chronic low back pain since 2001.  About 4 years ago, he had a local procedure which relieved his pain but however at baseline he used to experience 5/10 radiating to bilateral lower extremity up till the knees.  But for the past 2 weeks, this pain has worsened significantly to 10/10.  Denies any focal neurological symptoms including focal weakness, sensory disturbances, saddle anesthesia, bowel or bladder incontinence.  Denies any fall recently.  No any fractures.  Denies any fevers, rigors but did endorse chills.   No recent illness.  No COVID related symptoms.   He was evaluated at Hospital.  Labs, lumbar spine x-ray, and chest x-ray were obtained. Providers felt he qualified for observation admission secondary to his weakness, COVID-19 infection, and problems ambulating. Patient was discussed with the hospital service but was declined because he did not meet inpatient requirements. Providers felt like he needed longer term care with admission to a nursing home with rehab.    Son called nurse triage yesterday evening stating that the patient's back pain worsened following his presentation to facility earlier today. EMS were subsequently contacted and the patient now presents to the ED for further evaluation.    He has a walker at home.  But for the past week, he was confined to his recliner and even with minimal movement, he has been experiencing significant pain to a point he was not able to perform his ADLs.The patient endorses generalized weakness that is worse in the bilateral lower extremities.    Of note, he has been experiencing dysphagia to pills for the past 2 weeks and stated he has not been taking any of his medications especially pills.  Denies any chest pain, palpitations, dyspnea on exertion, orthopnea, PND.   He does have very minimal leg swelling.   Of note: he was admitted on 9/7/2021 for sepsis thought secondary to pneumonia with COPD exacerbation versus bilateral lower extremity cellulitis.  He was initially started on vancomycin, cefepime, Flagyl, and doxycycline.  Infectious Disease was consulted and deescalated antibiotics to IV ceftriaxone and oral doxycycline for 5 day course.  Eventually IV ceftriaxone was transitioned to cefdinir.  IV methylprednisolone was transition to 40 mg prednisone.  He was weaned from 4 L oxygen to 1 L at rest, ambulation, and overnight at discharge.