Age: 16.0
Sex: M
Vaccine: COVID19
Symptoms: Blood creatinine, Blood folate normal, Blood osmolarity, Blood sodium increased, COVID-19
Clinical narrative: Discharge Provider: MD  Primary Care Physician at Discharge: MD   Admission Date: 7/16/2022  Discharge Date: 7/30/2022  DETAILS OF HOSPITAL STAY: Shortness of breath [R06.02] Diarrhea, unspecified type [R19.7] Intractable vomiting with nausea, unspecified vomiting type [R11.2] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a  17-year-old male with history of epilepsy, cerebral palsy, VP shunt, chronic lung disease who presented on 7/16 with vomiting, diarrhea, and hypoxia. Initial workup included EKG, chest x-ray, complete blood count, CMP, D-dimer, and fluids, found to be COVID-19 positive. Initially there was concern for aspiration pneumonia, so he received one dose of Unasyn. On admission he met criteria for severe sepsis secondary to acute COVID-19 infection with associated lethargy/AMS, acute hypoxic respiratory failure, decreased oral intake with AKI, and gastroenteritis. Shunt studies and quick brain MRI were stable. He met criteria for VTE prophylaxis with lovenox. Treatment for COVID-19, including remdesivir and steroids, offered to parents on admission. Decided to defer remdesivir due to concerns for liver injury, completed 10 day steroid course. Restarted outpatient azithromycin in shared decision making with family. They would like to continue on discharge.   Hospital course complicated by many factors. Near the beginning of his admission, KUB was obtained due to diarrhea. Radiologist remarked on possible bowel obstruction. CT ab/pelvis was obtained, significant for pancolitis, no bowel obstruction. Patient with diarrhea throughout hospital stay. ID consulted and many stool studies were obtained, including enteric stool pathogens, basic O&P, adenovirus stool antigen, CMV IgG, IgM and quant. Studies were all negative. Diarrhea likely due to COVID-19 colitis. Started low-dose loperamide on 7/27 with improvement in quantity of diarrhea.   Given patient's continued tachycardia, increasing oxygen requirement, and hypercoagulable state, there was large concern for pulmonary embolism. Given patient's long history of radiation from CT scans, parents were understandably hesitant to proceed with further imaging. Duplex ultrasound of bilateral lower extremities was obtained, negative for DVT. V/Q scan could not be performed due to hospital protocol against performing scan on COVID + patients. His D-dimer continued to rise and risk of not imaging outweighed risk of further radiation, and CTA of the chest was obtained, which was negative for PE, but did show moderate-sized bilateral pleural effusions. Obtained Echo on 7/21 to rule out heart failure as cause for pleural effusions, was within normal limits. Physical exam notable for bilateral periorbital edema and pitting edema in the hands and feet. Pleural effusions thought to be due to fluid overload with low intravascular volume. Administered albumin and lasix on 7/22 with improvement on physical exam and pleural effusion size on x-ray. Unfortunately, patient experienced contraction alkalosis following lasix administration, limiting further diuresis. Nephrology was consulted and recommended administration of albumin without lasix. He received second albumin administration of 7/27 with resulting improvement in oxygen requirements. Intervention Radiology was consulted for drainage of pleural effusions, but size was not great enough for intervention.   NG was placed on 7/20 due to decreased oral intake and inability of patient to take oral anti-epileptic drugs. Enteral nutrition was also given via NG. Nutrition was consulted to recommend management of PO vs NG feeds. Patient began taking enough PO to meet daily nutritional needs at time of discharge. Additionally, he was able to tolerate administration of AEDs and Xarelto via PO.   CBC on presentation was notable for thrombocytopenia which continued throughout admission. This is likely due to COVID-19 suppression of bone marrow as well as adverse effects of his AEDs. Platelet count returned to normal on day of discharge.   He had three episodes of hematochezia on 7/21, etiology of which thought to be due to visible anal fissure compounded by lovenox use and thrombocytopenia.    He had two episodes of severe hypernatremia, as high as 156. The first episode was treated with IVF and frequent sodium checks. The second episode resolved without intervention. There was concern for diabetes insipidus given patient's central CNS defects. Urine and serum osmolality, sodium, and creatinine were obtained. Studies negative for DI. Sodium levels returned to normal prior to discharge.   Patient with macrocytic anemia on presentation. Monitored with daily CBCs. B12 and folate were normal. This is thought to be anemia of chronic disease exacerbated by COVID. He received one unit of PRBCs on 7/26. No infusion reactions. Hemoglobin increased from 6.7 prior to transfusion to 10.7 on day of discharge.   Patient was safe for discharge when he maintained his oxygen saturation above 94% on room air. Per pulmonary, he was safe for discharge with home oxygen up to 0.5L at night, though that was not necessary for over 36 hours prior to discharge. He was able to take all medications by mouth and maintain his nutritional status with PO intake.