Age: 28.0
Sex: F
Vaccine: COVID19
Symptoms: Exposure to SARS-CoV-2, Fatigue, Haemoglobin decreased, Hyponatraemia, Hypotension
Clinical narrative: Hospitalized (10.14.21-10.17.21);  COVID-19 positive (10.14.21);  fully vaccinated Discharge Provider: DO Primary Care Provider: DO Admission Date: 10/14/2021 Discharge Date: Oct 17, 2021 DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute kidney injury [N17.9] Pneumonia of left lower lobe due to infectious organism [J18.9] COVID-19 [U07.1] Acute pneumonia [J18.9] Cough [R05.9] Community acquired pneumonia, unspecified laterality [J18.9] HOSPITAL COURSE: This is a 28 y/o female with past medical history significant for spastic cerebral palsy, fetal alcohol syndrome, microcephaly, spina bifida, and chronic constipation with noted cecostomy tube. Patient currently resides at home under the care of her mother/DPOA. Patient was brought into the ED on 10/14 due to concerns of vomiting, cough, and possible blood coming out of her GJ tube.  Mother reported patient's symptoms started a few days prior to presentation. She stated that patient had been coughing and spiking low grade fevers. Mom also reported concerns regarding potential aspiration event at home. Patient is strict NPO with feeding tube in place. Grandson in the home recently tested positive for COVID thus mother was concerned patient may have this as well. Patient is fully vaccinated for COVID-19 however. Additionally mother reported what appeared to be blood coming out of her G tube. It appears patient has had issues with this in the past. Last EGD was noted to be in March of this year and was negative for any source of bleeding at that time. Otherwise mother reported that patient appeared fatigue and less alert/interactive then her baseline.  Upon arrival to the ED, patient was noted to be febrile/tachycardic/hypotensive. She was not hypoxic. Basic labs were obtained and notable for normal WBC, Hg of 8.8 which is patient's baseline, Na-130, AKI with Cr of 1.4, K-3.3, PCT-1.63, and positive COVID PCR. Patient underwent further evaluation with CXR which demonstrated mild left basilar atelectasis vs infiltrate. There was no evidence of significant COVID pneumonia. Patient received IVFs, Rocephin/Azithromycin, and IV protonix. IM was then asked to admit for further care. Following admission, patient was continued on Rocephin and Doxycycline due to concern for bacterial pneumonia with potential aspiration as mother reported aspiration episode at home. Azithromycin was discontinued due to prolonged Qtc. Blood cultures were obtained on admission and remained negative during hospital stay. Patient did not appear to have any significant respiratory compromise from COVID. AKI and hyponatremia resolved with IVFs. Hg was trended closely and dropped somewhat to 7.7 but overall remained stable. There was no evidence of bloody output from feeding tube. Patient was initially placed on IV Protonix. GI was consulted and given there was no evidence of ongoing bleeding, endoscopy was not recommended.  Nutrition managed tube feeds. Electrolytes including potassium and phos were low during hospitalization and were aggressively replaced. Patient otherwise improved back to baseline at time of discharge. She was noted to be alert, smiling, and interactive with mother. She will be discharged on Ceftin/Doxy to complete a total of 5 days of Abx. Mother was instructed to have patient follow up with PCP. Patient should have repeat labs including CBC, BMP, Mg, and Phos drawn within a few days of discharge.