Age: 29.0
Sex: M
Vaccine: COVID19
Symptoms: Productive cough, Protein total normal, Red blood cell count decreased, Red blood cell nucleated morphology, Red cell distribution width normal
Clinical narrative: "Hospitalized (1.25.22 - 1.28.22); COVID-19 positive (1.25.22); Fully vaccinated -pfizer x2  I have seen and examined with the APP   Lungs are clear   Diarrhea, interestingly has resolved after being inpatient   Admitted with RSV and COVID-19 infections in the setting of a patient with a lung transplant   Will discharge on steroid taper   He is status post IVIG   Will get ribavirin as an outpatient   He received Remdesivir.   35 minutes needed by me in the discharge of this patient    BRIEF OVERVIEW: Admission Date: 1/25/2022 Discharge Date: Jan 28, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 01/25/2022 Unknown ? Lung transplant status, bilateral for cystic fibrosis 08/29/2017 Yes  Discharge Disposition:  home or self care    Active Issues Requiring Follow-up:  COVID-19- Onset of Sx 01/2- 20 days quarantine recommended from the day of onset of symptoms.   Medication changes -CellCept decrease to 500 mg. -RSV-complete 3 additional days of prednisone 40 mg and thereafter resume 5 mg prednisone daily for immune suppression.  Ribavirin for additional 7 more days DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: RSV (acute bronchiolitis due to respiratory syncytial virus) [J21.0] COVID-19 [U07.1]   HOSPITAL COURSE: 29 y/o male with PMH of CF and BOLT 8/10/18. He presented to the ED with a 3 - 4 day history of feeling sick. Started with cough productive of small quantities of thick sputum and now with nausea and fatigue. The day prior he developed pleuritic left-sided chest pain. Film array reveals COVID 19 and RSV and was subsequently admitted for further treatment.  During the entire admission, patient was not hypoxic and did not have any respiratory complaints.  Infectious Disease was consulted, and patient received 3 days of remdesivir (no monoclonal antibody, after discussion between Infectious Disease and monoclonal antibody team due to equal efficacy between remedesevir vs MAB).  RSV-treated with 3 days of IVIG,Ribavirin (total 10 days).  On admission CellCept decrease to 500 mg daily.  Course complicated with elevated creatinine secondary to contrast received for imaging.  On the day of discharge creatinine downtrend to 1.64. CONSULTS / RECOMMENDATION: -Weight loss of about 9 kg since 05/2020 and follows up with dietitian.  Previously he has followed up with Peds gastroenterology due to dumping syndrome.  Recommend outpatient follow-up w/ GI. -ID- as above. INPATIENT PROCEDURES: None BP 134/71  | Pulse 67  | Temp 36.5 °C (Oral)  | Resp 18  | Ht 1.727 m  | Wt 50.3 kg  | SpO2 98%  | BMI 16.86 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance.     Comments: Thin  HENT:     Head: Normocephalic.     Nose: No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Cardiovascular:     Rate and Rhythm: Normal rate.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: No respiratory distress.     Breath sounds: Rales present. No wheezing.  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.     Comments: Scaphoid abdomen  Musculoskeletal:     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: He is oriented to person, place, and time.  Psychiatric:        Behavior: Behavior normal.  1/26/22: Infectious Disease Consultation Reason for Consult:  COVID-19 and RSV infection in patient who is status post lung transplant Inpatient Consult to Infectious Diseases Assessment: 1. Status post bilateral lung transplant (08/10/2018)   - CMV D+/R+; EBV D+/R+; toxo D-/R+ 2. COVID-19 infection - tested positive 01/25/2022.  Symptom onset 1/21/22.  Mild symptoms at this time. 3. RSV infection - mild symptoms at this time 4. Cystic fibrosis 5. Immunosuppressed   - Tacrolimus and mycophenolate   - Prophylactic acyclovir, azithromycin, and Bactrim   Plan: 1. Agree with remdesivir    - Given mild symptoms would follow outpatient treatment protocol of 200 mg on day 1 followed by 100 mg on days 2 and 3   - Please check CMP daily while on remdesivir   - Discussed with monoclonal antibody team given current limitations on the supply of remdesivir and Sotrivomab they would not treat a patient with both agents as they both have approximately equal efficacy with regards to presenting disease progression 2. RSV management as per transplant protocols  - Ribavirin 200 mg 3 times a day times 10 days    - Patient will need CBCs checked at least weekly for the next 4 weeks to monitor for anemia and neutropenia related to Ribavirin use  - IVIG 0.5 milligrams/kilogram daily x3 days  - Prednisone 40 mg daily x5 days 3. No need for antibiotics at this time Subjective:  HPI: Patient is a 29 y.o. male with past medical history significant for cystic fibrosis with need for lung transplant that was performed in August of 2018. He is currently hospitalized under the care of the lung transplant service.  Patient presented with increasing shortness of breath with mild productive cough associated with fatigue and runny nose.  Patient notes that he attended a birthday party for his stepson at a trampoline park where he was exposed to multiple individuals.  He reports that on Monday 01/24/2022 he was yelling at his TV while playing video games and noted acute onset left-sided pleuritic chest pain which persisted.  He has diarrhea at baseline but has not noticed any increase in diarrhea.  He is not experiencing nausea or vomiting.  He does endorse fatigue.  Reports that he is experiencing sinus pressure with associated headaches.  Denies having any fevers or chills. Initially upon admission he was hemodynamically stable, a respiratory panel resulted positive for COVID-19 and RSV.  The patient underwent a CT angiogram of the thorax which did not demonstrate a pulmonary embolism.  CT also did not demonstrate consolidation concerning for pneumonia.  The patient was started on REM does not hear at the time of admission and has subsequently been started on ribavirin by the Lung Transplant Service.  Today on interview he endorses continued sinus pressure and headache.  States that he is still intermittently experiencing a cough.  He is not requiring supplemental oxygen.    Objective:  Vitals: BP 133/62  | Pulse 95  | Temp 36.8 °C (Oral)  | Resp 16  | Ht 1.727 m  | Wt 50.3 kg  | SpO2 96%  | BMI 16.86 kg/m²   Wt Readings from Last 4 Encounters: 01/25/22 50.3 kg 11/30/21 49.4 kg 11/16/21 49.5 kg 11/04/21 50.8 kg    Physical ExamVitals reviewed.  Constitutional:     General: He is not in acute distress.    Appearance: He is not ill-appearing or toxic-appearing.  HENT:    Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: No oropharyngeal exudate or posterior oropharyngeal erythema.  Eyes:   General:        Right eye: No discharge.        Left eye: No discharge.  Cardiovascular:   Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: No murmur heard. Pulmonary:    Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing or rales.  Abdominal:    General: Abdomen is flat. There is no distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:       General: No swelling or deformity. Normal range of motion.  Skin:   General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not jaundiced.     Findings: No bruising. Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.