Age: 13.0
Sex: F
Vaccine: COVID19
Symptoms: Gastrointestinal tube insertion, Haematemesis, Haemodilution, Haemoglobin, Haemophilus test positive
Clinical narrative: Discharge Provider: MD  Primary Care Physician at Discharge: MD  Admission Date: 10/18/2022  Discharge Date: 11/09/2022 Covid positive date: 10/19/2022 Acute hypoxemic respiratory failure (HCC) [J96.01] COVID [U07.1]   HOSPITAL COURSE: Procedures: 1. PICC placement 10/21 2. Intubation 10/23 3. Fluoroscopically guided NJ placement 10/27   Consults: 1. Pulmonology 2. GI 3. Gynecology 4. Peds ID 5. PT/OT/SLP 6. Social Wok   Presentation: Patient is a 14 y.o. female with history of SMA, neuromuscular scoliosis, and restrictive lung disease who is admitted with acute hypoxemic respiratory failure in the setting of COVID-19 pneumonia requiring PICU and BiPAP, ultimately requiring intubation.    Hospital Course by System:    Respiratory/ENT:  Presented in hospital and quickly required escalation in respiratory support, ultimately to intubation on 10/22.  Aggressive pulmonary clearance to assist with clearance of secretions.  Empiric antibiotics added for possible superimposed bacterial pneumonia (H. Flu and S. Aureus). Treated with 5 day course of remdesivir and 14 day course of decadron for COVID and 7 day course of Ceftriaxone for bacterial pneumonia. Ventilator settings slowly weaned. Transitioned to PSV/CPAP on 10/29. Extubated on 11/2 and transitioned to BiPAP. BiPAP settings slowly weaned. Aggressive ariway clearance regimen maintained with albuterol, hypertonic saline, vest and cough assist every 4 hours. Transitioned to room air during the day on 11/6 and tolerated well, continued on night time BiPAP. Mother completed a room in on 11/7 with home BiPAP.    Cardiovascular: Lactate rose to 2.9 on 10/23 then subsequently normalized to 1.2 on 10/24. No other concerns. Monitored on continuous cardiac monitoring throughout admission.    Renal/Genitourinary: Normal electrolytes on admission with large derangements noted in K, Mg, Phos, and Ca after several days of NPO.  Corrected with repletion and supplementation in TPN.  Urinary retention noted after intubation and q6h intermittent catheterization initiated with subsequent foley placement on 10/23.  Intermittent lasix required for positive fluid balance and to support respiratory efforts. Foley removed on 10/26.   FEN/GI:  NPO on MIVF at admission. Started on TPN + IL after massive electrolyte derangements noted. Coffee ground emesis noted as NG output at the time of intubation with slow downtrend in hemoglobin and GI prophylaxis escalated from pepcid BID to pepcid and protonix BID. GI consulted, who did not recommend EGD, recommended starting carafate if hematemesis continued. TPN was discontinued on 10/24 and enteral tube feeds were initiated along with Mirolax and Senna. Increasing abdominal distension noted 10/27 and she was transitioned to NJ feeds with gastric decompression, which was tolerated well. Once on extending breaks off BiPAP, she was seen and cleared for regular diet with SLP. She resumed a regular diet with calorie counts. Coffee-ground emesis did not return and she was taken off pepcid. She continues on Protonix with a taper plan per pediatric gastroenterology.    Hematologic: Started on lovenox and SCDs as VTE prophylaxis due to immobility and COVID infection. Noted to have slow downtrend in hemoglobin after transfer to PICU, likely multifactorial from hemodilution, iatrogenic from blood draws, and possible upper GI bleed as NGT output was noted to be coffee ground at the time of intubation. Lovenox held 10/23-10/26 and restarted after NG output no longer appeared bloody. Lovenox also held 10/30-10/31 secondary to more NG output. Once restarted, lovenox was continued until discharge.    Infectious Disease: COVID positive on admission with sputum culture at the time of intubation grew Haemaphilus influenza and few MSSA. Completed 7 day course of rocephin. She was treated for Covid-19 with a 5 day course of remdesivir and 10 days of decadron.    Endocrine: No concerns   Neurologic/Pain/Sedation: Precedex, Fentanyl, and Versed used for pain control and sedation. Versed d/c'ed on 10/23. Precedex d/c'ed on 10/24. Fentanyl weaned on 10/24, transitioned to enteral morphine on 10/27. PRN ativan added 10/24 along with nightly melatonin and zyprexa. Enteral morphine wean initiated on 10/31 and completed on 11/4. She was weaned off of zyprexa. During her last few days prior to discharge, parents noted significant worsening of her anxiety and difficulty sleeping. MSW saw and gave resources for counseling. She was discharge home with 10 doses of hydroxyzine PRN for anxiety and will be followed up with her PCP.