Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: Hypotension, Malaise, Nausea, Pain in extremity, Pleural effusion
Clinical narrative: Pfizer COVID-19 Vaccine EUA  Pfizer Dose 1 3/18/21 (EN6207) Pfizer Dose 2 4/8/21 (EW0161) COVID Positive 4/23/21  4/22/21: Presnted to ED. The patient presents with Nausea and vomiting. A 73 year old female with a history of UTI and DM was brought to the ED today due to having nausea and vomiting for the past couple of days. She was administered Zofran by EMS; they checked her BS which was 171. The patient states she has been sick since the eighth of this month, and has had diarrhea, dysuria, and  arm pain. She reports not taking her insulin since February due to her insurance no longer covering her. .  The onset was 3  days ago.  The course/duration of symptoms is constant.  The character of symptoms is unknown.  The degree at present is moderate.  The exacerbating factor is none.  The relieving factor is none.  Risk factors consist of diabetes mellitus. Therapy today: emergency medical services.  Associated symptoms: diarrhea.  4/30/21: A 73-year-old female, history of hypertension, diabetes mellitus type 2 with chronic kidney disease, adrenal insufficiency from renal cell carcinoma and adrenalectomy, and nonalcoholic steatohepatitis with portal hypertension, esophageal varices, has had nausea and vomiting for several days.  She did receive her second COVID-19 vaccination on April 8, and has had ongoing symptoms since that time, much worse in the 3 days prior to admission. An initial COVID screen was negative, but rechecking the PCR COVID test was positive.  Initially, she did not require any oxygen, but did require 2 L nasal cannula at night on the second night, at which time remdesivir and convalescent plasma were administered.  She was also given dexamethasone, but had marked rise in her blood sugar to greater than 400. The dexamethasone was tapered and stopped.  Glucose regulated with insulin.  The patient initially had severe anorexia, poor oral intake, but this slowly improved.  CT scan of the abdomen and pelvis has shown the small nodular liver consistent with cirrhosis and portal hypertension.  There is some ascites and mild pleural effusions.  The patient had been receiving some IV fluids, and we would discontinue the Lasix because of low blood pressure.  There was no other obvious explanation for her poor oral intake or abdominal pain. The patient had IV access problems and eventually, despite the PICC line and midlines being attempted, we were unable to complete a successful IV to finish her CAP antibiotics or the remdesivir. The patient seemed to be doing better, oxygen is 98% on room air, blood pressure 98/63 and 116/60.  We are holding the Lasix, potassium, and spironolactone.  The glucose has been running at 213, 154, and 202.  BUN at 35, creatinine 1.4.  WBC 11,700 and hemoglobin 11.5. The patient was seen on the day of discharge at 1100 hours, doing quite well, and will be discharged home with her family.  We have offered visiting nurses, but she feels that the family is there 24 hours a day.  She does not need any visiting nurses.  We have made some changes to her medications, and she will need to follow up with her primary doctor in the next week to see whether we need to restart Lasix, potassium, and spironolactone. DISCHARGE MEDICATIONS:  Will be hydrocortisone 15 mg a.m., 5 mg evening, venlafaxine 37.5 daily, venlafaxine 150 mg at bedtime, rifaximin 550 mg b.i.d., Bactrim DS 1 daily, multivitamins daily, insulin glargine 35 units at bedtime, atorvastatin 20 mg daily, NovoLog 20 units before meals.  Again, we are holding Lasix, potassium, and spironolactone.