Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Dyspnoea exertional, Eosinophil percentage decreased, Fatigue, Full blood count abnormal
Clinical narrative: Hospitalized (2.17.22 - 2.20.22); COVID-19 positive (2.9.22-per home test / 2.17.22 -lab test); fully vaccinated PLUS Booster -moderna x3 d/c summary:Discharge Summary MD (Physician) ? ? Transplant  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: DO Admission Date: 2/17/2022 Discharge Date: Feb 20, 2022  Discharge Diagnosis: 1. Mild COVID pneumonia 2. Noted left PA thrombus, almost certainly chronic. No evidence of pulmonary hypertension Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 02/20/2022 Yes ? Pulmonary thrombosis Left 02/18/2022 Yes ? Right lung transplant due to IPF 04/09/2018 Yes ? Moderate protein-calorie malnutrition 03/05/2018   Discharge Disposition:  Home without services Active Issues Requiring Follow-up: Lung transplant clinic follow up to review need for anticoagulation DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Dyspnea   HOSPITAL COURSE: Presented with increasing dyspnea, fatigue. COVID positive on 2/9. Received mAb. CT angio with mild changes c/w on rt transplanted lung. Left native lung with large PA thrombus, likely chronic. Calcifications there previously noted on non-contrast CT. Split perfusion scans have shown essentially no flow to left side.    Treated with moderate dose steroids, 40 daily of MP. Improved clinically. No indication for remdesivir. BAL done with no secondary infection, but predominant neutrophils.   Anticoagulated during hospital stay. Plan to DC with ASA only CONSULTS / RECOMMENDATION: Consult Orders (From admission, onward) IP CONSULT TO INFECTIOUS DISEASES      Provider:  MD INPATIENT PROCEDURES: BP 137/77  | Pulse 86  | Temp 36.4 °C (Oral)  | Resp 16  | Ht 1.651 m  | Wt 48.5 kg  | SpO2 98%  | BMI 17.79 kg/m²    Physical Exam  rt lung clear. Decreased BS on left. Heart normal. abd soft, NT. No edema  2.18.22 -Transplant H&P:  PULMONARY ATTENDING ATTESTATION     I personally saw and examined the patient.  I personally reviewed imaging, labs, and other available data.  Management was discussed with the fellow and I agree with documentation with any exceptions noted here.  Brief exam: Patient is alert, resting comfortably in bed. Good air entry in right chest. Regular rhythm tachycardic.   Has had worsening dyspnea and fatigue since November 2021 but acutely worse in last 1 month.   Brief History and Medical Decision-Making: This is a 74 year old female s/p right single lung transplant in 2018 for IPF, now admitted with subacute dyspnea. She was diagnosed with COVID-19 infection on 2/9 and received MAB. CT angiogram in ED shows large central left main PA thrombus, however intravascular calcifications seen on CT non-contrast in May 2021 suggest that at least some element of thrombus was present then. She has elevated BNP and a dilated RV on CT, LE doppler are negative for DVT.   --on heparin drip  --Echocardiogram pending  --PERT discussion would be useful to determine next steps, the suggested chronicity of the thrombus would make mechanical thrombectomy less successful.   Principal Problem:    Pulmonary embolism on left   Active Problems:    Right lung transplant due to IPF  CHIEF COMPLAINT:      Pulmonary embolism on left  ASSESSMENT / PLAN:        Right lung transplant due to IPF Assessment & Plan Dyspnea on exertion  In the setting of submassive PE in the setting of COVID-19  Acuity of PE unclear  CTA with left main PA thrombus  Discussed with IR, suspicion this was present on non-con CT last year  Will await definitive recommendations  Could possibly be developing pulmonary hypertension as RV strain seen on CT chest  Will obtain echo to evaluate for RVSP and function  Continue heparin gtt for now  Re-discuss with IR  COVID-19 infection       Diagnosed on 2/9  S/p MAB  CT with no acute infection  S/p Right lung transplant       Immunosuppression: - tacrolimus level 2.7 goal 3-5 due to renal dysfunction              - increase dose, recheck levels in 1-2 weeks - everolimus level 4, goal 4-6 - myfortic 360 mg BID due to history of leukopenia - prednisone 5 mg daily Prophylaxis:      - bactrim M/W/F - Acyclovir BID              - patient interested in reducing pill burden, could consider stopping  - azithromycin M/W/F CKD, renal function stable Diverticulosis - Hx Constipation Hematological problems/Anemia  - post op blood loss anemia - HGB stable  (baseline 11 pre op) - Injectafer q week x2. (LD 5/6/18)   Fatigue, severe - home sleep study with significant desaturation              - recommend formal sleep study to r/o OSA-  - Vitamin D, and TSh wnl - no depression - does not sleep well Sciatica: - saw ortho/spine.  Started outpatient PT- not helping. DERMATOLOGY Alopecia - improving - Pt wearing wig (7/10/18) - Biotin PSYCHOSOCIAL Anxiety/Depression/Panic attacks since IPF advanced, worse immediate post-op  - Neuropsych Eval (6/20/18) - Psychologist, Dr. psychologist @ Psychological Services referral (7/10/18).              - F/U (7/18/18): patient feels great, cheerful. Does not want counseling at this time. - Escitalopram 20 mg --- > weaaned off (7/17/18). - Clonazepam --- > weaned off (LD 6/18/18) - Mirtazapine (FD 7/10/18) for depression and appetite stimulant. No longer taking - Buspirone H/O of Claustrophobia - CARE GIVER: husband, of 28 years,  HISTORY OF PRESENT ILLNESS: 74-year-old female with history of idiopathic pulmonary fibrosis status post single lung transplant in April 2018 presents today with increased dyspnea with exertion for the past 1-2 weeks.  She reports having fatigue ongoing since around Christmas time.  Husband and patient both have noticed that she has been very short of breath with walking minimal distances which is unusual after her lung transplant.  She reports an intermittent cough for the past couple of days bringing up a light green sputum.  She has had a positive at-home COVID test on 02/09/2022.  She called her lung transplant team that should come to the emergency department for evaluation.  She denies any chest pain.  She denies neck pain, body rash.  She does report her abdomen has felt itchy.  She denies any increase in nasal secretions or congestion.  No headache or sore throat.  She has had intermittent diarrhea which is not unusual for her.  No urinary changes.  She denies fevers, chills or night sweats. Review of Systems Constitutional:  Positive for fatigue. Negative for chills and fever.  HENT: Negative for rhinorrhea and sore throat.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough, shortness of breath and sputum production.   Cardiovascular:  Negative for chest pain and leg swelling.  Gastrointestinal:  Positive for diarrhea. Negative for nausea, vomiting and abdominal pain.  Musculoskeletal:  Negative for neck pain and joint pain.  Neurological:  Negative for headaches, dizziness and numbness/tingling.  Endo/Heme/Allergy:  Negative for adenopathy.  Psychiatric/Behavioral:  Negative for suicidal ideas.  Skin:  Positive for itching. Negative for rash.  OBJECTIVE: BP 173/94  | Pulse 123  | Temp 36.6 °C (Oral)  | Resp 28  | Ht 1.651 m  | Wt 48.2 kg  | SpO2 94%  | BMI 17.68 kg/m²    Physical Exam  Constitutional:      General: She is not in acute distress.    Appearance: She is well-developed.  HENT:     Head: Normocephalic and atraumatic.     Nose: No rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal.  Abdominal:     Palpations: Abdomen is soft.  Musculoskeletal:        General: No deformity.     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert and oriented to person, place, and time