Age: 21.0
Sex: F
Vaccine: COVID19
Symptoms: Gastrostomy tube site complication, Haemorrhage, Hypercoagulation, Illness, Inflammatory marker increased
Clinical narrative: Discharge Provider: MD  Primary Care Physician at Discharge: MD  Admission Date: 7/20/2022  Discharge Date: 7/27/22  Pneumonia due to COVID-19 virus    HOSPITAL COURSE: Patient is a 21 y.o. female with PMHx of Lennox-Gastaut, glycosylation disorder, G-Tube dependent, developmental delay and intractable epilepsy who presented to the ED 7/20 for presence of cough, increased secretions and fever of 101. She had a cough and congestion for over 1 week now,  Mom said she had fever at the beginning of illness receiving a course of Zithromax with some improvement. Day of admission, fever came back with a temperature of 101F, cough, increase in her secretions, and difficulty breathig associated with multiple episodes of vomiting.    When she arrived to the ED she was in distress and lethargic, with presence of tachycardia, she improved after 3 boluses of fluids, one dose of rocephin was given. Labs in the ED showed COVID 19 positive, PH 7.41, UA with no signs of infection, chest X ray with concerns for an atypical pneumonia, and abdominal x ray with moderate to large colonic stool burden and no evidence of pneumoperitoneum.Labs showed normal lactate, WBC 23 bandemia of 17%, non-anion gap metabolic acidosis. Procal 2.28. Blood cultures remained negative.   Upon arrival to the floor an AWARE was called due to tachypneic, tachycardia, fever, and low spO2.She was placed on 10 L venti mask. Deep suctioning and CPT helped and she was eventually weaned to RA. Rocephin was continued while inpatient. Pt also had two seizures overnight back to back. Sepsis stat also called, but no new orders resulted. She was also having a lot of g-tube secretions mixed with dark blood, and we consulted GI. We started Pepcid, carafate, and protonix. ID, Pulmonology, Hematology-Oncology, Palliative, and Neurology were also consulted. Pulmonology recommended starting pulmicort and decadron. Neurology gave recommendations for AEDs and IV formulations due to inability to tolerate enteral AEDs.   Due to her COVID19 infection, MISC labs were obtained which showed elevated ferritin, CRP, BNP, troponin, and D-dimer. An echo was completed which showed normal RV and LV function with some septal flattening. Dexamethasone was started, and over the next few days all of these inflammatory markers trended downwards except for the D-Dimer and BNP, both of which rose. Lovenox was started on the recommendation of Heme-Onc, and cardiology was consulted for the elevated BNP, but given her normal cardiac examination, they did not recommend a further echocardiogram in an asymptomatic patient.   After a couple days of treatment with PPI, carafate, and Pepcid (7/23/22), there was no further GI bleeding noted from the G-tube resolved, so enteral feeding was started via her G-tube. Carafate and pepcid were stopped but protonix continued in part due to the GI bleed and also because of the steroids. She was also transitioned back to her outpatient seizure medications (via G-tube) as well. After her first night in the hospital, she had no further seizure activity, and she tolerated her medications well. Patient also had a liquid form of topamax sent to the pharmacy to make dosing easier.   Towards the end of patient's admission, she started having slight vaginal bleeding, which was thought to be her normal period. She was overdue for her Depo shot, but given the hypercoaguability of COVID-19 infection, this shot was deferred. Per Heme-Onc, this risk lasts for approximately 45 days, although the literature is not conclusive.   Over the course of her admission, pt.'s parents also had productive conversations with palliative care. They came to the decision that short term intubation was acceptable, but not long term ventilation. They were also interested in defibrillation in certain circumstances where it could help the patient, but not cardiopulmonary compressions.   Patient's lung exam progressively improved with suctioning, chest PT, hypertonic saline and a pulmonary regimen inculding flovent and albuterol. On the day of discharge, her lungs were largely clear, and secretions were minimal. During the last couple days of her admission, the patient's feeds were accelerated back to her baseline, and she tolerated them well. On 7/27/22 the patient was considered stable for discharge home, and patient's mother was happy and comfortable with the patient's condition.