Received Jun 30, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | UNK | 3058190 | IM / LA |
Acute change in mental status/delerium from baseline starting day after vaccine administration, 2 falls/found on floor 4 days. New elopement risk/exit seeking. Trazodone PRN agitation/exit seeking
None
ICD-10 Personal history of urinary (tract) infections Z87.440 04/08/2026 Active ICD-10 Chronic diastolic (congestive) heart failure I50.32 04/08/2026 Active ICD-10 Hypokalemia E87.6 03/10/2026 Active ICD-10 Cough, unspecified R05.9 01/13/2026 Active ICD-10 Dementia in other diseases classified elsewhere, unspecified severity, with agitation F02.811 01/13/2026 Active ICD-10 Repeated falls R29.6 05/21/2025 Active ICD-10 Paroxysmal atrial fibrillation I48.0 05/21/2025 Active ICD-10 Alzheimer's disease, unspecified G30.9 05/21/2025 Active ICD-10 Chronic kidney disease, stage 3b N18.32 05/21/2025 Active ICD-10 Obesity, unspecified E66.9 05/21/2025 Active ICD-10 Hyperlipidemia, unspecified E78.5 05/21/2025 Active ICD-10 Essential (primary) hypertension I10 05/21/2025 Active ICD-10 Hypothyroidism, unspecified E03.9 05/21/2025 Active ICD-10 Muscle weakness (generalized) M62.81 05/21/2025 Active ICD-10 Unsteadiness on feet R26.81 05/21/2025 Active ICD-10 Need for assistance with personal care
acetaminophen 325 mg tablet Every 4 Hours - PRN 2 tabs = 650mg, oral, Every 4 Hours - PRN, PRN Temperature >101F 01/13/2026 Active ammonium lactate 12 % cream At Bedtime thin layer, topical, At Bedtime, Apply thin layer to BLE at bedtime
No known allergies
UA negative