Age: 62.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Thrombocytopenia, Ultrasound Doppler normal, White blood cell count decreased
Clinical narrative: Hospitalized 12/18/2021-still admitted currently; COVID-19 positive 12/18/2021; fully vaccinated plus booster  Assessment and Plan   COVID 19 Pancytopenia with neutropenia Anemia of chronic kidney disease Sepsis on admission Vaccinated Moderna 01/05/2021, 02/02/2021, 09/24/2021 SIRS 3 criteria met: HR 112, RR 22, TEMP 36.7, WBC 1.61 WBC 1.61 with absolute neutrophil count 1.23, hemoglobin 10.3, platelets 75k COVID 19 detected by PCR: 12/18/2021. Symptomatic day: 6 Current oxygen saturation 95%, oxygen requirement room air Severe Respiratory isolation Will not start Decadron or remdesivir as patient is not hypoxic Daily labs CBC with differential, CMP, CRP, D-dimer  Continuous pulse oximetry Due to pancytopenia TSH was ordered found to be normal.  LDH slightly elevated.  Patient has a history of anemia of chronic kidney disease this is likely the etiology of her low hemoglobin.  Will order B12 and folate even though MCV normal.  Order peripheral smear.  Awaiting blood cultures and urine culture. Her white blood cell count was normal 11/02/2021 and her platelet count 93 was improved.  I think the likely etiology of her leukopenia and thrombocytopenia is related to COVID-19 infection and this will continue to improve.  However will await additional lab results. Threshold for platelet transfusion is 10,000 if no signs of bleeding or 50,000 if signs of bleeding Would recommend starting broad-spectrum antibiotics if absolute neutrophil count drops below 0.500 No signs of bleeding Consider reaching out to Hematology Will ask the day team to reach out about monoclonal antibodies 12/21/2021 note: Patient had worsening respiratory status today and required supplemental oxygen. She denies any chest pain, swelling in arms or legs, or new cough.  Plan:  - Current oxygen saturation 88%, oxygen requirement 3.5L NC - Severe Respiratory isolation - Start Decadron this morning due to increasing oxygen requirements. Patient is on day 8 of symptoms with poor renal function so will not do Remdesivir at this time. Due to rapidly worsening status will start IV Solumedrol this evening and continue with 1 mg/kg/day dosing.  - Start heparin drip due to new onset worsening oxygen requirement and concern for PE. Unfortunately due to patient's renal function she would not be a candidate for CT angio. This also precludes the use of Lovenox. Ordered Doppler US of all 4 extremities. 12/24/2021 notes: Plan:  - Current oxygen saturation 92%, oxygen requirement HFNC 50L @ 65% FiO2, this is marginally better than yesterday. - Patient also has a superimposed bacterial pneumonia which may play a part in her pancytopenia. Treat bacterial infection.  12/29/2021 notes: Acute respiratory failure with hypoxia Assessment & Plan Due to bilateral lung infiltrates from COVID-19 viral pneumonia, with probable superimposed bacterial pneumonia, +/- additional atypical pneumonia Strep pneumo urine Ag positive, for which she already completed 7 days of abx (ceftriaxone/cefepime combo) Given chronic immunocompromise (chronic steroids/Cellcept), with recent high dose steroids, atypical process such as fungal pneumonia to be considered Did not require oxygen on admission, but developed hypoxia within 24-48 hrs of admission. Oxygen needs have since been escalated to HFNC 60L 85% FiO2. Most recent CXR 12/27 with mildly improved/stable bilateral lung infiltrates Some fevers on admission, however, afebrile over the past 7-8 days  Continue steroids for COVID-19 pneumonitis, as above AKI has resolved, with renal function now back to baseline. Agree with stopping IVF so as to not precipitate pulmonary edema. Goal even fluid balance. No evidence of DVT thus far based off of U/S studies. Echocardiogram with normal RV size/thickness/function, not suggestive of PE (at least not a large or hemodynamically significant PE). Normal LV EF 59%. Would continue heparin 5000 units Q8 hrs for DVT ppx and continue to observe clinically for signs/symptoms that would suggest VTE.