Age: 6.0
Sex: M
Vaccine: COVID19-2
Symptoms: Mucosal dryness, Pneumonia bacterial, Procalcitonin increased, Pyrexia, Rales
Clinical narrative: Discharge Provider: Primary Care Physician at Discharge: Admission Date: 2/17/2024  Discharge Date: 2/19/2024 DETAILS OF HOSPITAL STAY: Pneumonia of both lungs due to infectious organism, unspecified part of lung [J18.9] Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1]   HOSPITAL COURSE:   Patient is a 7 y.o. male with a PMHx of deceased donor kidney transplant (April 2023) on Tacrolimus, seizures, G-tube, and deafness with bilateral cochlear implants who was admitted on 2/17/2024 due to difficulty breathing in the setting of COVID-19 pneumonia and secondary bacterial pneumonia.    On 2/9, dad reports that he took pt. to the walk-in clinic after he was noting ear pain.  At that time, the provider noted that his ear "looked red" and was given a prescription for Amoxicillin in case symptoms worsened over the weekend. Dad reports that he did not administer any antibiotic doses as pt. never broke a fever.  On 2/12, pt. developed a cough and congestion which dad treated with cold medicine. On 2/16, pt. came to stay with mom who noticed he seemed to be having difficulty breathing.  Overnight, symptoms worsened and she reached out to the Nephrology team who recommended presenting to the emergency department.    Upon presentation to the ED, pt. was afebrile with a respiratory rate of 60.  Oxygen saturations were 92% on room air.  On initial exam, he was tachypneic and rales were noted in the left lower lobe.  He appeared dehydrated with delayed capillary refill and dry mucus membranes.  Was given a normal saline bolus and started on 2L nasal cannula.  Initial workup was significant for elevated procalcitonin (0.97), normal wbc, and normal electrolyte levels.  Tacrolimus level was within normal limits.  CXR demonstrated subtle asymmetric opacities that may represent peribronchial thickening (consistent with a viral process), atelectasis, or pneumonia.  Right chest port was visualized with a venous catheter tip along the superior mediastinum, however the catheter tip appears to take sharp turn to left.  While in the ED, he developed a fever to 38.4°C and was given a dose of Rocephin.  Film array was positive for COVID-19. Admitted to the general floors under the Nephrology service for further evaluation and management.   He was continued on home medications and started on continuous Pedialyte via G-tube to ensure appropriate hydration. Infectious disease was consulted and felt that pt. was an appropriate candidate for Remdesivir therapy and received a 3-day course (2/17 - 2/19). Due to his elevated procalcitonin, new onset fever, and left lower lobe opacity on CXR, decided to continue treatment for a secondary bacterial pneumonia and he received 2 additional doses of daily IV Ceftriaxone. Examination of his ear did not reveal an acute otitis media. During admission, he had daily labs (to assess for transaminitis and depression of cell lines in the setting of Remdesivir) and his Tacrolimus levels were monitored (as Remdesivir can lead to increased serum Tacrolimus). On 2/18, he was able to wean off supplemental oxygen to room air.   Repeat 2-view CXR on 2/18 demonstrated the tip of the right chest port catheter present in an atypical position in the azygous vein. Parents report that pt's chest port has been functioning without difficulty at home since placement on 5/1/2023. Consulted general surgery who felt port was appropriate to use as needed and recommended follow-up for repositioning after resolution of COVID infection. No surgical intervention indicated at this time. Attempted to obtain an Echo to further verify placement, but images were unreadable due to agitation. Per surgery, stable for discharge.    On day of discharge, pt. was afebrile with stable vital signs on room air and was clinically improved on exam. Peripheral blood cultures negative at 48 hours. Mom noted that he is due for a G-tube change, but his G-tube supplies (16 french, 2.0 cm mini one button) are not available in the hospital. Instructed family to pick up a prescription of PO Amoxicillin from the pharmacy to complete a total 5-day course of antibiotic therapy for pneumonia (4 additional doses from 2/20-2/21). Provided family with contact information to schedule an appointment with general surgery for port repositioning. Discussed attending pt.'s previously scheduled follow-up appointment at the Nephrology clinic with Dr. on 2/28/2024.   Reviewed return precautions that would necessitate evaluation by a provider in the clinic or return to the Emergency Department.  All questions and concerns were addressed.  Family was agreeable with this plan and pt. was discharged home in stable condition.