Received Mar 10, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | 2 | EW0171 | UN / UN |
Name: Medical Record #: Age: 67 y.o. DOB: 11/X/19XX Admit date: 3/3/2025 Discharge date: 3/5/2025 Admitting Physician: MD Attending Physician at the Time of Discharge: DO Primary Care Physician: PAC Reason for Admission: Right trimalleolar fracture Hospital Course: Patient is a 67 YO F with PMHx of stage I vulvar cancer, type 2 diabetes mellitus, hypertension, chronic obstructive pulmonary disease, CKD 3, chronic pain/fibromyalgia who presents after syncopal event with right leg pain and found to have unstable right trimalleolar fracture, status post ORIF on 3/4 by Dr. Post operative pain was difficult to control, but on the day of discharge she was well controlled with oxycodone 10 mg every 3 hours. She received radiation therapy in the hospital. She and her husband refused placement as she is essentially wheelchair-bound at baseline, following surgery was nonweightbearing right lower extremity on day of discharge. She was discharged home with home healthcare services on 3/5/2025