Age: 17.0
Sex: F
Vaccine: COVID19
Symptoms: Hyposplenism, Hypoxia, Intertrigo, Laboratory test, Leukocytosis
Clinical narrative: Date of Admission  01/04/2022   Date of Discharge  01/06/2022   Reason for Hospitalization   Pt mother reports "my daughter needs seen in ER for labs and COVID testing". pt reports nausea and vomiitng but no fevers.  Hospital Course   Patient is a 18-year-old female with Hb SS s/p bone marrow transplant in august 2020 who presented to the ED on 1/4 for concerns of upper respiratory symptoms, backslash leg pain and hypoxia requiring oxygen support and got admitted to the inpatient peds heme-onc team with Covid pneumonia.  Initial labs were done in the ER patient was admitted on maintenance IV fluids for hydration and home medications.  On admission infectious disease was consulted and recommended starting remdesivir 200 mg on day 1 and 100 mg starting day 2.  Patient was also started on IV dexamethasone to help with the inflammation of the lungs.  She was also started on Lovenox (therapeutic dosing) based on prior history of stroke and increased susceptibility to blood clots with COVID-19 infection.  Patient developed fever shortly after admission and so Rocephin was started q24hrs while monitoring the blood cultures.  Based on the history it was noted that the patient had a new rash with started along with the symptoms about 10 days prior to admission so dermatology was consulted based on concerns of graft-versus-host events as patient has an immunocompromise state which was ruled out and Vaseline bid was recommended for irritant dermatitis and intertrigo.  Yesterday 1/5 patient underwent echocardiography to rule out any myocarditis which was within normal limits.  Repeat labs of CBC and CMP were unremarkable and ESR CRP were markedly elevated likely due to the Covid infection.  Patient was noted to have been requiring some low flow oxygen intermittently during nighttime when she is in deep sleep but did well during the day.  Yesterday there was improvement in her oral intake with good urine output and bowel movement.  No fevers reported in the last 24 hours and this morning patient was examined bedside and was noted to be well-appearing.  She did not require any low flow overnight and sats were maintained above 95%.  Patient has a follow-up with dermatology in 3 weeks for the rash.  Blood cultures so far have been negative with no growth. Third dose of remdesivir, ceftriaxone and dexamethasone were given today and ID recommended no further need for remdesivir and was comfortable with how pt did in the hospital. Family is comfortable going home and strong return precautions were provided prior to discharge with script for lab work to be done in 1 week.  Discharge Diagnoses      1. COVID  -ID consulted  -received 3 doses of steroids and Remdesivir   2. Rash (Irritant dermatitis)  -Derm consulted  -F/u with derm in clinic in 3 weeks  -Vaseline bid   Orders:   cefTRIAXone, 2 g, form: Injection, IVPB, Once, Routine, first dose 01/06/22 11:00:00 CST, Physician Stop, stop date 01/06/22 11:00:00 CST, 100 mL/hr, infuse over 30 minute(s), 50  Other Diagnoses   Ongoing  Asthma  BMI 33.0-33.9,adult  Chronic headaches  Epilepsy  History of CMV  Homozygous sickle cell (SS) disease  Hx of allogeneic stem cell transplant  Hypertension  Hypogammaglobulinemia  Immunocompromised state  Iron overload  Obesity  Peripheral neuropathy  QT prolongation  Historical  Acute chest syndrome in sickle cell disease  Acute constipation  Acute cystitis  Acute gastroenteritis  Dehydration  Dizziness  Fever  GERD - Gastro-esophageal reflux disease  Headache, new daily persistent (NDPH)  Ovarian cyst  Right atrial thrombus  Sickle cell pain crisis  Thrombus  Transcranial doppler ultrasound velocimetry  Operations and Procedures   none  Consultants   Infectious Disease    Dermatology   Pending Labs  Culture Blood (Preliminary, InProcess, ordered 01/04/2022, 09:20)   Culture Blood (Dispatched, Ordered 01/04/2022, 09:20)   Discharge Disposition  home  Medications  New, Changed, or Refilled Medications  None    Medications to be Continued  LORazepam (LORazepam 0.5 mg) 0.5 mg, 1 Tablet(s), Oral, q6h, PRN: as needed for anxiety, 0 Refill(s) Comments: Prescribed by HCF Hem/Onc/BMT   albuterol (albuterol  HFA 90 mcg/ 2 Puff, Inhalation, q4h, for 30 day(s), PRN: Wheezing, 0 Refill(s)    azithromycin (azithromycin 250 mg 250 mg, 1 Tablet(s), Oral, qM W F, 0 Refill(s)    cholecalciferol (Vitamin D3 25 mc 25 mcg, 1 capsule(s), Oral, Daily, 0 Refill(s)    escitalopram (escitalopram 10 mg) 15 mg, 1.5 Tablet(s), Oral, Daily, 0 Refill(s) Comments: Prescribed by HCF Hem/Onc/BMT   fluticasone (Flovent HFA 110 mcg/ 2 Puff, Inhalation, bid, PRN: Wheezing    gabapentin (gabapentin 300 mg) 900 mg, 3 capsule(s), Oral, tid, 8am, 3pm, and 8pm  Instructions:8am, 3pm, and 8pm  lactobacillus rhamnosus GG (Cultu 1 capsule(s), Oral, Daily    levETIRAcetam (Keppra 500 mg) 1,500 mg, 3 Tablet(s), Oral, qAM, 0 Refill(s)    levETIRAcetam (levETIRAcetam 1000 1,000 mg, 1 Tablet(s), Oral, qEvening, 0 Refill(s) Comments: Prescribed by HCF Hem/Onc/BMT   levothyroxine (levothyroxine 200 200 mcg, 1 Tablet(s), Oral, qAM    loratadine (loratadine 10 mg) 10 mg, 1 capsule(s), Oral, Daily, 0 Refill(s)    montelukast (montelukast 10 mg) 10 mg, 1 Tablet(s), Oral, qEvening, 0 Refill(s)    oxyCODONE (oxyCODONE 5 mg) 5 mg, 1 Tablet(s), Oral, q6h, PRN: Pain, Breakthrough, 0 Refill(s)    penicillin V potassium (penicilli 500 mg, 1 Tablet(s), Oral, bid, 0 Refill(s)      Discontinued Medications  None  Physical Exam at Discharge  Vitals & Measurements  T: 36.1 °C  TMIN: 36 °C  TMAX: 37.5 °C  HR: 87  RR: 16  BP: 117/76  SpO2: 97%      General: Alert, active, no acute distress.   Head: Atraumatic and normocephalic.  Eyes: Pupils equal round and reactive to light. Extra ocular movements intact. Normal conjunctivae.  ENT: Oropharynx dry without erythema, lesions, inflammation, or exudates.  Cardiovascular: S1-S2 heard.  Regular rate, regular rhythm.  No murmurs, rubs or gallops heard.  Capillary refill less than 3 seconds.  Good Radial pulses felt bilaterally.  Respiratory: Clear to auscultation bilaterally and no wheezes/Rales heard.  No signs of respiratory distress noted.  Abdominal: Soft, nontender and nondistended.  Bowel sounds heard in all 4 quadrants.  MSK: Moves all extremities equally with good strength and good tone.  Reports diffuse tenderness to palpation over the upper back.  Skin: Dry eczematous looking rash with erythematous border noted over the fold of the right armpit.   Neuro: Alert and oriented to time place and person.  Cranial nerves II to XII grossly intact.  Psych: Normal mood and appropriate affect.     Follow Up Appointments     Derm in 3 weeks (a MU representative will give a call to family)  Nursing/Other Orders   Regular Diet. Ordered on 01/04/22 13:23:00 CST, Meal Start Time Breakfast 0700 to 0900   Intake and Output (I&O). 01/04/22 13:23:00 CST, Continuous Order   Activity As Tolerated. 01/04/22 13:23:00 CST, Continuous Order   Code Status. Code Status Description: Full Code      Attestation by MD, on January 06, 2022 14:25 I personally saw and evaluated the patient on the result date found in the header of this document.  I independently performed the critical/key portions of the Evaluation and Management service and discussed the management with the author of this document.  I agree with everything documented above with the following exceptions/additions:  Patient is an 18 yo female with Hgb SS disease now ~15 months s/p allogeneic stem cell transplant at a HCF.  She was admitted on 1/4 for Covid-19 pneumonia with hypoxia.  She received remdesivir and dexamethasone x 3, as well as Rocephin due to fevers on hospital day 1.  Blood cultures remain NGTD.  She was able to tolerate RA prior to discharge, both while awake and sleeping.  Pain in her legs and chest has resolved.  She notes a small amount of continued pain in her upper back; however, has significantly improved and is manageable at home.  PO intake has normalized. No additional VTE prophylaxis necessary at this time.  Will call if fever, chest pain, or shortness of breath recur.  Will obtain CBC, reticulocyte count, and CMP locally on 1/10 as Hgb has decreased to 8.7 g/dL this AM. Results to be faxed to the HCF who will also coordinate follow-up as necessary in their clinic.  Dermatology to follow-up as outpatient for evaluation and management of irritant dermatitis and intertrigo.  Dermatitis not felt to be due to GVHD.  Mother at bedside at time of discharge who acknowledges understanding and agreement with plan. Diagnosis:  1. Covid-19 Pneumonia  2. Hgb SS disease  3. History of allogeneic stem cell transplant  4. Functional asplenia  5. Acute pain, resolved  6. Fever due to #1, resolved  7. Hypoxia due to #1, resolved  8. At risk for thrombosis due to #1 and #3, improved  9. Moderate anemia  10. Dermatitis  11. Mild leukocytosis with neutrophilia due to steroids