Age: 62.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Urine ketone body present, White blood cell count increased
Clinical narrative: REASON FOR ADMISSION COVID-19 Infection   HOSPITAL COURSE Patient is a 62 y.o. female who presented to the Emergency Department (ED) on 10/08/2021 for worsening diarrhea in the setting of a COVID-19 infection.  Patient  has significant medical comorbidities chronic pouchitis on rotating flagyl and cipro 2/2 total proctocolectomy w/ ileal pouch-anal anastomosis (2014) d/t ulcerative colitis, PSC s/p liver transplant (11/2017), pyoderma gangrenosum, and CKD III (baseline creatinine unclear, but has ranged from 1.4-2.3 in the last year).    Per chart review, patient has been in town for her four year posttransplant follow-up appointments.  She underwent a pouchoscopy for for surveillance on 10/06/2021 that was uncomplicated.  She then contacted the on-call liver transplant pager around 2300 on 10/07/2021 with complaints of chills, shakes, nausea without vomiting, decreased oral intake, and increased bowel output.   On arrival to the ED patient was hemodynamically stable and in no acute distress.  She was found to have an SpO2 of 89% and was placed on 2 L supplemental oxygen via NC with subsequent improvement.  Laboratory studies were obtained.  CBC revealed WBC 16.9 with neutrophils 13.82.  CMP was notable for a bicarbonate of 21, BUN of 31, creatinine of 2.38, and a total calcium of 10.5.  Lipase was 46.  Lactate was 1.2.  Urinalysis was notable for trace ketones, trace blood, and 30 protein.  COVID testing was positive.  Recent imaging including CXR and liver ultrasound were unremarkable/stable from previous examinations.  Pouchoscopy on 10/06/2021 revealed anal canal stenosis and a single erosion in the neoterminal ileum with known inflammation and the ileoanal pouch 2/2 pouchitis.  Patient was given 1 L NS in the ED and is being admitted  for ongoing evaluation and management.   On arrival to the  medical floor patient was hemodynamically stable. Regarding her current COVID infection, patient was vaccinated against COVID-19 with the Pfizer series on 03/19/2021 and 04/13/2021.  She states that she had not attended any large social gatherings or public events in the last several weeks.  She noted that she consistently wears a mask when out in public.  However, patient noted that her daughter and son-in-law do not "believe in COVID" and so they are not vaccinated and do not take safety precautions while in public. Patient visited with her daughter and son-in-law on 09/29/2021 who were feeling ill with symptoms of headache and upper respiratory congestion at the time of their visit.  Patient then began to feel fatigued, weak and noted muscle aches on 10/02/2021.  Given her transplant status, Infectious Diseases was consulted and recommended remdesivir, and dexamethasone if indicated.  Respiratory status, inflammatory markers and labs were monitored closely.  Collateral workup was obtained and excluded other acute COVID-related complications.  Fortunately, her respiratory status improved.  Weaning from O2 was successful.  Home oxygen evaluation was performed by RT on 10/11.  She was found to NOT quality for homegoing oxygen therapy.    Overall, her hospital course was uncomplicated. Medical staff was consulted to assist with her immunosuppression medications.  Her Tacrolimus trough was elevated at 9.2.  Her Tacrolimus dose was decreased and a repeat trough is trending.  Of note, her urine cultures were checked due to a high WBC.  They came back positive but because she was asymptomatic, no antibiotics were administered.  She remained hemodynamically stable throughout her stay on the medical unit.  She completed a 5 day course of Remdesivir.  She demonstrated progressive improvement on the aforementioned therapies.  Care Management consulted and assisted with discharge planning.  Discharge to hotel with friend who will drive back to home with her was arranged on 10/12.  She was assessed for Monitoring Program for which she is a candidate.  Isolation precautions and criteria for discontinuation are outlined below.  Additional ambulatory follow-up with PCP, dermatology, transplant, and GIH was arranged prior to dismissal.