Age: 37.0
Sex: M
Vaccine: COVID19
Symptoms: Cough, Fatigue, Inflammatory marker increased, Myalgia, Pyrexia
Clinical narrative: Patient vaccinated 3/26/2021, admitted 8/1/2021, tested positive for COVID 8/2/2021. discharged 8/3/2021 to home  Date of Vaccination: 3/3/2021 Dose: 1 Vaccine Manufacturer: Pfizer Lot #: ER8732 Clinic Administering Vaccine: Clinic Injection site: L deltoid Date of Vaccination: 3/26/2021 Dose: 2 Vaccine Manufacturer: Pfizer Lot #: EN6203 Clinic Administering Vaccine: Clinic Injection site: L deltoid  Description of event/reaction: presented with COVID infection post-vaccination  Date of Clinic Visit or Hospitalization: 8/1/2021 Reason for clinic visit or hospitalization: COVID+ (dry cough, fever, weakness) COVID-19 positive test result: Yes, date: 8/2/2021  Chief complaint: COVID +   History Of Present Illness Patient is a 37 y.o. male with history of chronic kidney disease status post renal transplant in 5/85, 10/88 and 10/2006.  He is currently on Sirolimus and Azathioprine.  On Saturday he went to a fair.  Saturday evening patient developed mild dry cough, fever and generalized weakness.  Today his fever ranged to 102-105F.  He took some Tylenol.  Then he was tested positive for COVID at urgent treatment center. Family called renal transplant clinic and instructed patient to come to the hospital for evaluation.  Patient denies sore throat, dyspnea, diarrhea, loss of taste or smell. He is vaccinated. Currently patient patient's vital signs are stable. Talked to Dr from Nephrology and recommended no treatment at this time and will need formal renal transplant consult in a.m. And hold am dose of sirolimus and Azathioprine until he is evaluated by renal transplant in am.  This encounter used interpreter.  Wife is at bedside also.    Review of Systems  Constitutional: Positive for fatigue and fever.  Respiratory: Positive for cough.   Neurological: Positive for weakness.  All other systems reviewed and are negative.  Hospitalization Admit Date/Time: 8/1/2021  8:58 PM Discharge Date: 08/03/21 Referring provider name and address:  No referring provider defined for this encounter.   Chief Concern, Brief History of Present Illness, and Hospital Course Patient is a 37 y.o. man with a history of ESRD secondary to renal dysplasia s/p LRKT in 10/2006, with prior transplants in 1985, 1988, admitted with Covid-19. Patient presented with high grade fevers 102, some associated dry cough, though no prominent dyspnea, after attending a ceremony. He had received Pfizer vaccine in March 2021 per patient and completed vaccine series. Patient reported fever, chills,and myalgias. He was tested for Covid-19, which returned positive Sunday morning. Family contacted transplant clinic, and they were advised to present to the ED for further evaluation. He reports some associated dry cough, though no prominent dyspnea, and fevers up to 102 at home. Symptoms now improving with scheduled Tylenol. CXR on admission showed low lung volumes without obvious infiltrates. Inflammatory markers were mildly elevated,. He remained stable without fevers and his respiratory status was closely monitored and he required no O2.. Patient will be a candidate for outpatient bamlanivumab and will followed by renl clinic Pt is Chronic kidney disease status post renal transplant in 10/2006 and he was found to have a mildly elevated creatinine at 1.4 which improved to 1.28 with careful hydration. Patient was seen by renal transplant team and recommended reinitiating  home sirolimus and Azathioprine. Pt will be followed in transplant clinic   On the day of the discharge pt had no fever, chills, nausea, vomiting and cough or sob. He verbalized understanding to f/u in clinic and felt ready to go home