Age: 28.0
Sex: M
Vaccine: COVID19-2, FLU4
Symptoms: Aggression, Arteriovenous fistula site haemorrhage, Blood culture positive, Blood potassium increased, COVID-19
Clinical narrative: Discharge Provider: MD Primary Care Provider: DO Admission Date: 1/12/2023 Discharge Date: Feb 12, 2023  PRESENTING PROBLEM: Sepsis [A41.9] Sickle cell disease with crisis [D57.00] COVID-19 virus infection [U07.1]   HOSPITAL COURSE: 28 y.o. male with medical history significant for sickle cell disease, iron overload due to frequent transfusions, ESRD status post failed transplant in 2009 now on home hemodialysis, hypertension, GERD, prior MRSA bacteremia.  Presented to ER for fever, generalized pain.  Multiple recent admissions.  Admitted 8/23-9/23/2022 for acute sickle cell pain crisis, pneumonia secondary to COVID-19, treated with Decadron.  Readmitted 10/31-11/15 for acute encephalopathy and fevers, found to have MRSA bacteremia.  Source felt to be his port which was removed 11/3 with recommendation to use AV fistula going forward. Completed 4 weeks of IV vancomycin on 12/01.  Readmitted 11/26-1/1/2023 due to bleeding from fistula site, vascular surgery stitched site and recommended not using fistula for dialysis access, required CVC placement for emergent dialysis due to potassium of 7.2.  Underwent PermCath placement by IR on 11/29.  Unfortunately developed prolong sickle cell pain crisis requiring IV narcotics, also received 4 units PRBC during stay.  Finally discharged on 01/01.  Underwent vein mapping on 01/11, study showing bilateral cephalic and basilic veins not suitable for AVF creation but bilateral brachial veins are.  Over the past week, has been having worsening generalized pain.  Patient seen by Hematology (Dr.) on 01/12, labs drawn showing hemoglobin 5.3 with plan for 1 unit PRBC transfusion on 01/13 but patient developed fever at home and presented to ED.  In ER, T-max 102.6° F, noted to be tachycardic. Lab significant for hemoglobin 4.5, WBC 15.29, labs otherwise stable.  Found to be COVID-19 positive.  CXR suggestive of mild fluid overload.  Blood cultures drawn.  Patient started on IV vancomycin empirically given concern for catheter malfunction as well as prior MRSA bacteremia.  Additionally, 2 units PRBC ordered for hemoglobin <6.   On admission patient continued on IV vancomycin.  Blood cultures taken on admission 2/2 bottles returned positive for MRSA.  Infectious Disease consulted.  Interventional Radiology consulted.  PermCath removed 1/15.  IV vancomycin continued.  Repeat blood culture taken 1/16 showed resolution of bacteremia.  Vas cath placed for HD access 1/17.  Echocardiogram showed ejection fraction 60%.  Good visualization of aortic mitral pulmonic and tricuspid valves without evidence of vegetation.  With clearing of bacteremia, ID recommended continuing vancomycin with dialysis with end of therapy date of 02/27/2023.   Nephrology consulted and patient continued on Tuesday Thursday Saturday dialysis schedule.  PermCath was removed on 01/14, with Vas-Cath placed for HD on 01/17.  With clearing of bacteremia, IR was consulted, with PermCath placed on 01/23.   Patient is a home dialysis candidate.  However given the need for his antibiotic therapy which cannot be arranged at home he has an interim chair at Clinic from Monday 02/13/2023 till the completion of antibiotic therapy through 02/27/2023 to be dialyzed Mondays Wednesdays and Fridays.  His recommended to arrive at 12:15 on Monday 02/13/2023 to get his dialysis and antibiotic therapy.   On admission patient in sickle cell crisis.  Placed on p.r.n. oxycodone plus IV Dilaudid.  Patient did require multiple transfusions, receiving 3 total units of blood during his hospitalization.  Patient was given Desferal with all transfusions given his iron overload.  Patient was treated with oral oxycodone and IV Dilaudid.  Patient was not given Dilaudid PCA due to concerns for opioid stacking due to ESRD.  Patient's hemoglobin was 8 on 02/11/2023.  He felt better as we wean him off IV Dilaudid.  He was discharged home with the 3 days worth of oxycodone.  He will follow-up with his PCP and his nephrologist.  ID indicated that there was no need for ID follow-up after completion of antibiotic therapy.   Pain medication was difficult to wean, as patient was reluctant and aggressive in nature when weaning was discussed.