Age: 79.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Alanine aminotransferase normal, Aspartate aminotransferase normal, Basophil count decreased, Basophil percentage decreased, Blood alkaline phosphatase normal
Clinical narrative: Arrival Date: 2/14/2021  Discharge Date: 2/18/2021  Primary Discharge Diagnosis: Principal Problem: Sepsis (HCC) POA: Yes Active Problems: GERD (gastroesophageal reflux disease) POA: Yes Portal hypertension (HCC) POA: Yes Thrombocytopenia (HCC) POA: Yes Esophageal varices (HCC) POA: Yes Chronic systolic heart failure (HCC) POA: Yes Essential hypertension POA: Yes Hyperlipidemia POA: Yes  Operations/Procedures:  None   Pertinent Diagnostic Studies:  Xr Chest 1 View-portable  Result Date: 2/15/2021 Portable chest at 0039 hours HISTORY: New left internal jugular catheter. AP sitting portable chest compared to February 14, 2021 and shows introduction of a left internal jugular catheter with the tip doubled back on itself possibly in the distal brachiocephalic vein. No evidence of pneumothorax. There is a coarse appearance to the pulmonary interstitium bilaterally some of which may reflect chronic disease though the possibility of a very small infiltrate at the left base retrocardiac cannot be excluded and has not changed. No significant pleural effusion or definite acute vascular congestion. The heart, mediastinal and hilar structures are not enlarged or changed. Degenerative disease of the spine is noted with a mid thoracic scoliosis convexity to the right.   Left internal jugular catheter in place with distal tip curved back on itself possibly in the distal brachiocephalic vein. Chronic interstitial lung disease bilaterally as well as what may be a small focal infiltrate at the left base unchanged.  Xr Chest 1 View-portable  Result Date: 2/14/2021 PROCEDURE: XR CHEST 1 VIEW-PORTABLE HISTORY: cough COMPARISON: 9/27/2020   Impression: Limited portable view obtained. Heart mediastinum stable There is mild central vascular and interstitial prominence which could reflect developing mild interstitial edema or interstitial pneumonitis. No severe CHF. Some slightly more focal patchy increased interstitial airspace opacity in the left lower lobe retrocardiac region is identified and could represent a developing infectious inflammatory infiltrate. Clinical correlation and follow-up advised   Incidental findings:  CXR- Chronic interstitial lung disease bilaterally as well as what may be a small focal infiltrate at the left base unchanged.  Test Results Pending at Discharge: Pending Labs  Order Current Status  Microscopic Urinalysis In process  Blood Culture Peripheral Preliminary result  Blood Culture Peripheral Preliminary result   Active Issues Requiring Follow-up: ISSUE- Needs to follow up with PCP   Discharge Medications:  Discharge Medications   New Medications  Sig  cefpodoxime 200 MG tablet Commonly known as: VANTIN Start taking on: February 19, 2021 Take 1 tablet (200 mg total) by mouth daily. Do not start before February 19, 2021. Quantity: 6 tablet  Discharge Disposition: Home Or Self Care   Code Status: DNR  Details of Hospital Stay   History of Present Illness (from the H&P) CHIEF COMPLAINT: Chills fever, nausea, vomiting, diarrhea after receiving Covid vaccine #2 (Pfizer)   HPI: This is a 79 y.o. female with a past medical and surgical history as below-most significant for breast cancer that was diagnosed in 2017, portal hypertension secondary to fatty liver in 2019, resultant esophageal varices that bleed presents with the following chronological history: Approximately 9 AM yesterday morning she went to the clinic for her second Covid vaccination. At that time her temperature was 97.3. She felt fine the rest the day.   At 1 AM she woke up with shakes. She continued with nausea and that resulted in vomiting and then diarrhea. She also had severe pain in her thighs. This was severe enough that she called the ambulance.   Patient also relates later that she had had some burning on urination 2 days prior to the vaccination. She had leftover Macrodantin that she took 9 PM yesterday.   Also relates back in December she was seen by Dr for vaginal infection and 2 times a week she has to administer intravaginal antibiotics.   She has had multiple GI bleeds secondary to esophageal varices and is followed regularly by Dr who has had to do multiple banding procedures on her.   She also relates she has an enlarged spleen and is followed by Dr.   In the emergency room she was noted to be febrile and hypotensive. She received a total of 5 L of normal saline in the ER to bring her pressures up with a systolic below 100. She has a very elevated procalcitonin as well as lactic acid. Urine is positive for large amount of blood and small leukocyte esterase  Hospital Course 79 y.o. year old female with HTN, infiltrating ductal carcinoma of the right breast stage I status post lumpectomy with positive margins was on anastrozole but taken off secondary to abnormal liver enzyme testing, CLL/thrombocytopenia stage I with no treatment needed, fatty liver complicated by portal hypertension/splenomegaly resulting in bleeding esophageal varices, history of viral cardiomyopathy in 2006, B12 deficiency, history of admission for septic shock, chronic diarhea, presented to the emergency room on 2/14 complaining of fevers, myalgias fatigue nausea and vomiting 24 hours after having a second dose of COVID-19 vaccine. She was admitted for septic work-up and later found to be hypotensive after 7L of fluids and was transferred to the ICU for septic shock, left IJ was placed. Source of infection found to be septic from UTI. Urine culture sterile with less than 1000 colony forming units and blood cultures no growth to date.  On the day of discharge. Shock resolved. Her procalcitonin trended down. Wonder whether she had an exaggerated response to the Covid vaccine given that today the urine culture shows no growth.   Regarding acute on chronic diarrhea she had unremarkable GI PCR and diarrhea improved after starting Imodium. She is had extensive work-up for this with GI as outpatient and days colonoscopy planned in the near future.      CLL with splenomegaly/nodular hyperplasia of the liver with noncirrhotic portal hypertension/neutropenia/thrombocytopenia/hyperbilirubinemia/esophageal varices requiring banding in the past -Was restarted on propanolol and midodrine prior to discharge.  -Chronic stable anemia/B12 deficiency-getting supplementation every 3 months   Thrombocytopenia -she did have drop in platelet counts during admission while being on pantoprazole and Lovenox and these were discontinued and platelet count stabilized. She can have repeat CBC as outpatient to document improvement in platelet count. She was not noted to have any platelet type bleeding.   History of right-sided breast cancer status post lumpectomy was on anastrozole but stopped secondary to liver disease  Lab Studies: Lab Results  Component Value Date  GLUC 86 02/18/2021  CALCIUM 8.4 (L) 02/18/2021  NA 149 (H) 02/18/2021  K 3.8 02/18/2021  CO2 23 02/18/2021  CL 114 (H) 02/18/2021  BUN 18 02/18/2021  CREAT 0.9 02/18/2021   Results from last 7 days  Lab Units 02/16/21 0702  MAGNESIUM mg/dL 1.9   Lab Results  Component Value Date  CALCIUM 8.4 (L) 02/18/2021  PHOS 2.4 (L) 02/17/2021   Results from last 7 days  Lab Units 02/18/21 0724 02/14/21 1855  WHITE BLOOD CELL COUNT Thou/uL 4.1 < > 2.9*  HEMOGLOBIN g/dL 10.0* < > 8.8*  HEMATOCRIT % 30.0* < > 27.7*  PLATELET COUNT Thou/uL 33* < > 37*  NEUTROS PCT % -- -- 84.7  NEUTROS ABS Thou/uL -- -- 2.40  LYMPHS PCT % -- -- 10.9  LYMPHS ABS Thou/uL -- -- 0.30*  MONOS PCT % -- -- 3.1  MONOS ABS Thou/uL -- -- 0.10*  EOS PCT % -- -- 0.8  EOS ABS Thou/uL -- -- 0.00  BASOS PCT % -- -- 0.5  BASOS ABS Thou/uL -- -- 0.00  < > = values in this interval not displayed.   Lab Results  Component Value Date  ALT 28 02/18/2021  AST 15 02/18/2021  GGT 22 09/09/2019  ALKPHOS 116 02/18/2021  BILITOT 1.0 02/18/2021   Physical Exam at Discharge   Last Vitals: BP 117/70 (BP Location: Left arm, Patient Position: Lying) | Pulse 73 | Temp 98.1 °F (36.7 °C) (Tympanic) | Resp 18 | Ht 1.626 m (5' 4") | Wt 73.2 kg (161 lb 6 oz) | SpO2 94% | BMI 27.70 kg/m²   Patient was seen and examined by me on the date of discharge.   General Appearance: Alert, Awake, not in acute distress. Cardiovascular: S1-S2 regular, no murmurs present. Respiratory: Bilateral air entry present, no added sounds heard Gastrointestinal: soft, non-tender, non-distended, bowel sounds present. Extremities: B/l LE edema   I spoke with the patient regarding the discharge plan. The discharge plan was discussed with the case management and the nursing staff. Patient verbalzied understanding of the discharge and was agreeable for the discharge plan. Called pt;s husband to give update on care plan but got voice mail.   Condition on Discharge: Improved