Age: 50.0
Sex: F
Vaccine: COVID19
Symptoms: Fall, Full blood count normal, Haemoglobin normal, Hypertension, Loss of personal independence in daily activities
Clinical narrative: Covid + on 10/22/2021. Hospitalized. per ED Note: Patient is a 50-year-old female with past medical history multiple sclerosis presenting to the emergency department chief complaint of generalized weakness. The patient states he has had generalized weakness over the past 4-5 6 days and she has had frequent falls. She uses a wheelchair to get around her home and states that she has been self catheterizing herself for urine over the past 20 years. She states over the past 4 to 5 days she has felt so generally weak that she has fallen multiple times while trying to transfer from her wheelchair to the toilet. The patient otherwise complains of bilateral upper foot pain. She denies fever, chills, chest pain, shortness breath, cough, abdominal pain, nausea, vomiting, diarrhea, urinary symptoms, numbness, loss of coordination. Initial MDM: 50-year-old female presents the emergency department complaining of generalized weakness. Patient has fallen multiple times. She is on blood thinners. She did not hit her head that she can remember. Did not lose consciousness. Physical exam is as above. Vital signs within normal limits outside of mild hypertension. Will order bilateral foot x-rays, chest x-ray, EKG, labs   Was seen and evaluated by myself and my attending supervisor Dr.   Radiology imaging, EKG/Rhythm strip, and lab work (if obtained) were reviewed and interpreted by myself and my attending physician unless otherwise noted below. These were interpreted as normal or not significant to current complaint unless otherwise noted below.  CBC unremarkable, urinalysis consistent with mild urinary tract infection, BMP unremarkable, total CK within normal limits, TSH within normal limits.   CT head without contrast shows no acute intracranial abnormality  1 view chest x-ray shows no acute cardiopulmonary disease  Bilateral foot x-ray shows no fracture   EKG interpreted by myself and my attending physician: 10/21/2021, 1302, rate 72 beats minute, normal sinus rhythm, intervals within normal limits, normal axis, no significant ST elevation or depression, no significant T wave changes Course/Re-evaluation:   patient is unable to perform activities of daily living without difficulty at home and states that she has stabbing difficulties transferring from wheelchair to toilet without falling. The patient agrees to staying in the clinical decision unit for observation for neurology as well as PT/OT/social work evaluation. Per CDU Note: Pulse oximeter noted to be of good saturation at 100% on room air.  Twelve-lead EKG noted to reveal a normal sinus rhythm rate of 72 bpm there is no evidence of acute ST-T wave changes noted with a normal PR interval.  Laboratory testing did reveal a normal white blood cell count of 6760 with a stable hemoglobin of 12.3 the urine analysis appeared to be contaminated.  The chemistries were unremarkable.  Chest x-ray, x-ray of both feet and CT scan of the brain were all noted by the radiologist to reveal no acute finding.  The Covid screen was noted to be positive.   Spoke with Dr. covering another Dr. Case was discussed and plan is to admit the patient to her service.  Nursing asked me to go back to the bedside.  The patient indicated that she does not want to be admitted.  I did reaffirm that she had COVID-19.  And that could very well be contributing to her general weakness.  She states that the weakness is from her multiple sclerosis and does not think COVID-19 has anything to do with it.  I did tell her at this point in time that if she chooses to be discharged we will discharge her.  However if she changes her mind she may return at any time.  I also told her to isolate herself from other people for the next 10 to 14 days.  She was asked to follow-up with her primary care physician.