Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: White blood cell count
Clinical narrative: 9/26/21: admitted for progressive fatigue, SOB and COVID. Empiric ABX 9/27/21: O2 sats stable on 3 liters, home dose. Diarrhea, check CDiff. Leukopenia, ID consult. PT/OT. BRB per rectum, Hgb slightly down. GI consult ABX stopped 9/28/21 - No changes, dyspnea with exertion and coughing, one loose stool that was dark today. Stable on 3 iters O2. Monoclonal ab given. HGB stable 9/29/21 - Feels a lot better today 9/30/21 -stable for dischargeg       HOSPITAL COURSE: New Today: - Stable for discharge. Care plan upon discharge              > S/P MAB 9/28/21, baseline O2 requirements 2 liters at rest/4 liters activity. Doing pulmonary clearance exercises, cough improved, CXR improved - get CT thorax today for new baseline              > Immune suppression - keep AZA off until WBC improved and COVID symptoms improved. Continue Prednisone 40 mg x 5 days (to complete 10 day course)  then back to 5 mg. Tacrolimus dose reduced to 2 mg bid, goal 4-6              > Beta blocker on hold - keep off as HR 55-65              > Had BRB per rectum, improved by discharge, GI would like pateint on PPI BID and setting up outpatient colonoscopy              > CKD improved with improved oral intake              > HOLD fosamax as CRCL is to low, re-evaluate with endocrine as outpatient              > Resume home dose of eliquis              > Leukopenia - improved, will monitor              > PT evaluated and stable for home              > Labs and telemedicine appt next week, clinic appt when out of quarentine   -----------------------------------------------------------   Progressive weakness/Fatigue/Dyspnea COVID 19+ - 9/26/21 admit to the inpatient transplant service for further evaluation and IV antibiotics - administer 1 L NS fluid bolus for hypotension, re-evaluate and repeat bolus as needed - blood cultures, sputum cultures, repeat film array, strepotoccus and legionealla urine antigen ordered - start ceftriaxone and azithromycin 500 mg PO daily until above results are available - COVID +  - ID consult (9/27/21), D/C ABX, not candidate for Remdesivir, looking into MAB - 9/28/21 MAB given - Completed 5 days of dexamethosone, then 5 days prednisone 20 mg - BLE US neg   AKI - Fluid bolus   BRB per Rectum - hold ASA and Apixaban - GI consult - hgb stable, rec PPI bid and outpatient colonoscopy   S/p left single lung transplant (2012) complicated by previous A3 rejection (2013), now with CLAD, grade 2  - continue current immunosuppressive and prophylactic regimen, O2 dependent     -------------- other medical problems -----------------------------   Left Single Lung Transplant (9/1312)   - Lung function  (Best FEV1 2.26),(Best FEF 25-75 2.39) - HRCT (5/7/19): Chronic GGO LUL and lingula, slightly increased from (10/17/18) could be 2/2 scarring or sequela of prior infection. No significant air trapping. Dilated main PA consistent with pHTN. Cholelithiasis.  - HRCT ( 7/1/20) - Stable - DSA (5/22/19): DPI is potential DSA   Admission 12/25/20 - 12/28/20: fall with multiple rib fxs   Hx ACR  - TBBX (5/10/13): A3 BO, cleared (2/28/17): A0 BX  - TBBx (11/2018): A0 B0 C0   BOS Grade: 2 - Not on azithromycin 2/2 allergic reaction -- > Restarted (FD 10/16/18) - records states she is on it and she denies significant hives or other reactions. Discontinued from allergy list. - Graft function: Has BOS grade 2. Peak PFTs are FEV1 2.26 and FEF25/75 2.39.  - 12/2020: PFTs: FEV1 2.01, FVC 1.34, FEF25-75 0.74 - 7/2021  BOS Grade: 2              - continue Symbicort, azithromycin, and statin for BOS   Chronic hypoxemic respiratory failure Moderate obstructive lung disease, Moderate diffusion impairment  Likely due to BOS - Overnight oximetry (11/2018) study done, showing multiple episodes of hypoxemia.  - Sleep referral; (12/6/18):  2L O2 via NC ordered for nightime. - Hypoxia with activity (5/29/19:): qualifies for 2L oxygen with activity. - 10/8/20:  Using up to 4L O2 with activity since 6MWT in July.   Cough: - ENT referral (10/28/19) - VFSS (12/2/19): oral phase WNL, mild pharygeal dysphagia. No aspiration. Rec: General solids, compensatory strategies and GERD precautions   Rhinitis- Zyrtec 10mg qd (FD 4/15/19) for nasal drainage - Fluticasone 1 spray each nostril bid   Left LLL Nodule - CT (10/17/18): resolution of nodule/opacies LLL. Persistent GGO LLL > LUL, unchanged 12/2017. No air trapping - CT (5/20/19):  Increase in ground glass and tree in bud opacities - CT 6/30/20:  Stable. - CT (8/27/21): no mention in report.    Right lower lobe lung nodule: - 12/25/21:  CT thorax done after fall and admission - There is a 14 mm ovoid density within the inferior lateral right lower lobe (series 4 image 52). This may represent a transient inflammatory process, however, developing pulmonary mass is not excluded (native lung) - repeat CT:  8/27/21:  Interval decrease in size of previously noted pulmonary nodule, now measuring 1.1 cm.               - repeat CT in 6 months (~4/2022)   Immunosuppression - MMF allergy, 2/2 MMF induced colitis, do not trial - AZA 150mg - Tacro (Goal 4 - 6) renal - Prednisone 5 mg   ABX Prophylaxis - PJP: Bactrim MWF - CMV status (D+/R+): no prophy at present. CMV PCR and BAL negative (11/14/18) - Ampho B NEB q daily (PTA): life long 2/2 home environment    Mycobacterium gordonae on BAL from (8/2018). BAL (11/14/18): negative, no fungal elements   Parainfluenza/Infectious Pneumonia (8/2018) - S/P levaquin and pred x 5 days after broad spectrum abx   Rhinovirus tracheobronchitis (9/2021)   Cardiology: - Cardiology (7/31/19): lexiscan stress test normal. Recommend continue medical therapy. Next appt (4/14/19) - ECG (5/29/19): NSR - ECHO (6/6/19): EF 58%. LV and RV normal. LA moderately dilated. No AS, trace MR - Lexiscan (8/6/19): normal - NT pro BNP (6/11/19): 416 - 4/23/20:  Based on symptoms of shortness of breath, orthopnea, and edema will lncrease lasix to 40 mg daily and monitor response. She has monthly labs for her transplant meds so her renal function can closely be monitored.  BMP with scheduled labs tomorrow and then will need BMP in one month--Activity as tolerated, We recommended following a heart healthy, low fat, low cholesterol diet. - Lasix stopped due AKI - 10/8/20:  Message sent asking about updating ECHO--10/27/20:  Plan for echocardiogram with bubble study due to dyspnea and hypoxia per pulmonology.   Plan lexiscan nuclear stress test due to dyspnea and coronary artery disease risk factors. ECHO 10/30/20. - Stress test:11/20/20:  The stress test was symptom negative. Significant EKG changes are not noticed during stress test.  Myocardial perfusion imaging is normal.  Normal left ventricular systolic function with left ventricular ejection fraction at 86 % and normal left ventricular wall motion .  Tissue attenuation is absent   HTN/Tachycardia - ASA 81 mg  - Metoprolol 12.5 mg bid (FD 6/20/19) - held at admit   H/O AFib. S/P Ablation - Apixaban   Hx DVT/PE  - Life long antiocagulation. Currently Apixaban - VQ scan (5/2019): negative for PE   Venous Insufficiency BLE/Edema - Vein Clinic (9/20/19): vein insufficiency in right greater saphenous V. and left small saphenous V. Compression stockings 20-30 mmHg at least 8 hrs/day. Walk for 30" 5x/wk.  - Furosemide 20mg qd (FD 6/20/19): much improved - 4/23/20:  Cardiology appt:  Based on symptoms of shortness of breath, orthopnea, and edema will lncrease lasix to 40 mg daily and monitor response - Lasix causing AKI, stopped (and wasn't helping LE edema)   Dyslipidemia - Pravastatin 40 mg qhs - Omega 3 1,000 units 2 tabs q lungh    Renal CKD - Stable continue to monitor avoid nephrotoxins.    Hematologic Chronic Anemia - FeSO4 325 mg q lunch  - 10/8/20:  hgb dropping over the last year.  Plan iron labs and referral to Dr's office. - 4/19/21:  Office visit with hematology:   Asymptomatic with stable hgb, if trending down, proceed with BM biopsy to r/o MDS.  Follow labs q3months, f/u 6 months.   Gastrointestinal GERD - Esophagram (11/12/18): reflux to proximal esophagus - pH probe/man (12/18/19): 100% incomplete bolus clearance, no significant status. Normal pressures. DeMeester 41.5, GERD to proximal esophagus. Rec: anti-reflux surgery, will schedule after winter. - Message (4/15/19) sent to Dr's team to work on getting patient scheduled for GI Surgery - Stopped zantac BID (6/21/19), started protonix 40 mg qd 2/2 constant bad taste in mouth --- > increase to bid 2/2 worsening GERD --- > daily - Referral to Dr (6/27/19): patient will call for appt- 8/19/19-- 10/9/19:  In and out of network benefits the same, patient aware along with Dr's. Dr (11/20/19): > Okay for toupet fundiplication - 4/29/20:  GI surgery put on hold d/t covid.  Plan reschedule in 3 months.  She will need to hold eliquis 3 days prior to surgery. - GI surgery scheduled 7/30  -gallstones on CT 6/3020- consider lap chole at time of fundoplication.  Reviewed with Dr.  With all of her other non-transplant medical problems, I'd only want to take out her gallbladder if it was symptomatic.  She does not have biliary colic - 7/30/20:  Toupet fundoplication and hiatal hernia repair on 7/30/2020.  UGI the following morning-- no leak and mild delay in esophageal emptying. She tolerated oral liquids  -  9/17/20: f/u appt- diet is unrestricted and he stopped her PPI.    H/O CDiff   Endocrine Hypothyroidism. S/P Partial Thyroidectomy - Levothyroxine 200 mcg qam --- > decreased (4/23/19) to 175 mcg daily; repeat blood testing in 8 weeks. - SOB symptoms increased (6/10/19) since change in dose of levothyroxine. TSH 0.53 and Free T4 2.1 (6/11/19) --- > decrease to 150 mcg. Recheck in 4-6 weeks.  - Levothyroxine decreased (11/2019) by endocrine 137 mcg, repeat level in 3 months- not drawn.  Will order with annual labs in July 2020-- 4.87   Bone Health/OP - H/O bone fracture - Followed (10/29/18): no changes at present, F/U 6 months. - (4/29/19): monitoring labs looking for causes in osteoporosis, SPEP levels high- they placed referral to heme for further review. - (6/20/19): Continue fosamax until 2020. Continue calcium +D BID, f/u 6 months. - DEXA (6/26/19): osteopenia. Bone density has improved, will continue alendronate. - Calcium plus D 315-200 bid  - Vitamin D 1,000 units q lunch  - Ergocalciferol 50,000 units q 14 days -- 4/27/20:  Will recheck vit D level in one month to see if she still needs this dose-- 5/29/20:  Stop ergocalficerol.  Recheck level in 6 months-- vit D25:  55 - Alendronate 70 mg q Sunday    12/25/20: fall with  Multiple rib fxs Admitted 12/25/20, discharged 12/28/20 - Analgesia and IS for rib fractures - Left ESP catheter per anesthesia, acetaminophen, gabapentin, methocarbamol and OxyIR 2.5 mg - Aggressive pulmonary toilet   Osteoarthritis/RA. S/P Left TKA (5/18/15)   Oncologic / Cancer screening Skin CA - Right forearm excision (6/11/2019):  Squamous cell carcinoma- cutterage and dissection done.  F/u skin check in 6 months. - SK left uppper arm- liquid nitrogen done - 5/26/20:  Annual skin check-- everything looks good.  F/u 1 year, last visit 7/2021 no concerns.-- SK- removed by liquid nitrogen    Colonoscopy: 2013, 10/8/20:  Message sent to Dr asking if she had EGD during surgery, if not, can she have one when the colonoscopy is done.  Then need to order colonoscopy. - 11/9/20:  EGD/colonoscopy:  Previous anti-reflux procedure in the esophagus. Intact fundoplication below diaphragm.  The esophagus, stomach and duodenum appeared normal.  No esophagitis or esophageal erosions present grossly. No hiatal hernia present.  Bx:  Distal esophagus, biopsy:  Mild acute esophagitis. Colonoscopy:  All areas appeared normal, One sessile polyp removed-- Cecal polyp, biopsy:- tubular adenoma   Mammogram: 2019, advised to repeat mammogram during clinic visit on 7/13/21 Pap:   Psychosocial: Lives at home with her husband, and daughter 7/13/21: reports she is very active, walking 2-4 miles and takes care of her grandchildren.