Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Blood alkaline phosphatase increased, Blood bicarbonate decreased, Blood bilirubin increased, Blood calcium decreased, Blood chloride increased
Clinical narrative: Hospitalized (12.20.21 - 12.23.21); COVID-19 positive (12.20.21); Fully vaccinated -pfizer x2 D/C Summary: Discharge Summary Physician ? ? General Medicine BRIEF OVERVIEW: Discharge Provider:  Primary Care Provider:  Admission Date: 12/20/2021 Discharge Date: Dec 23, 2021    Active Hospital Problems   Diagnosis Date Noted POA ? Pneumonia due to COVID-19 virus 12/20/2021 Yes ? Hypoxia 12/20/2021 Yes ? Acute renal failure (ARF) 11/15/2018 Yes   Resolved Hospital Problems No resolved problems to display.    Pre-Existing Active Problems   Diagnosis Date Noted POA ? Peripheral vascular disease, unspecified 08/06/2021 Unknown ? Hyperparathyroidism, unspecified 08/06/2021 Unknown ? Platelets decreased  08/06/2021 Unknown ? Cirrhosis of transplanted liver  08/03/2020 Unknown ? Status post kidney transplant 08/03/2020 Unknown ? Immunosuppression  08/03/2020 Unknown ? Insomnia disorder related to known organic factor 11/30/2018 Unknown ? Anemia of chronic renal failure 11/14/2018 Unknown ? CRF (chronic renal failure), stage 3 (moderate) 02/05/2016 Unknown ? CRF (chronic renal failure), stage 4 (severe) 08/01/2015 Unknown ? Nuclear senile cataract of both eyes 03/06/2012 Unknown ? Hypermetropia of both eyes 03/06/2012 Unknown ? Recurrent skin cancer 11/28/2011 Unknown ? Status post liver transplant  06/24/2010 Unknown ? Non-ischemic cardiomyopathy 06/24/2010 Unknown ? Hemosiderosis on liver biopsy 06/24/2010 Unknown ? Osteoporosis 06/24/2010 Unknown ? liver anastomosis 06/24/2010 Unknown ? Aortic stenosis 06/24/2010 Unknown ? stenosis portal vein 06/24/2010 Unknown ? Pancytopenia  01/10/2010 Unknown     Discharge Disposition:  home health care svc    Active Issues Requiring Follow-up:  Patient will follow-up with her transplant service on Monday after getting her tacrolimus levels.  She has been advised to increase her fluid intake in the short term.    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1]   HOSPITAL COURSE: 66-year-old female with a past medical history significant for immunosuppression due to history of liver and renal transplant who presented to the emergency department with complaints of nausea, diarrhea, and shortness of breath on exertion.  She was found to have COVID-19.   Patient did require oxygen on admission to the hospital.  Based on her duration of symptoms and need for hospitalization with oxygen use, she was precluded from monoclonal antibiotic therapy.  Her mycophenolate was held in the setting of her acute illness.  Her prednisone dose was thought to be in need of increased and she was placed on initially methylprednisolone and subsequently after that 40 mg of prednisone daily.  Her tacrolimus was held on admission and tacrolimus level was checked in the setting of AKI.  With her AKI, it was suspected that she was suffering from volume depletion therefore IV fluids were started and Nephrology was consulted.   Patient was seen in consultation by Nephrology who agreed with holding tacrolimus and mycophenolate initially and providing IV fluids.  Patient was also seen in consultation briefly by Gastroenterology by Gastroenterology had nothing to offer in regards to use of the patient's immunosuppressive agents.  Patient's transplant service was contacted and they agreed withholding mycophenolate and once tacrolimus level came back greatly elevated at 28, they also agreed with holding of tacrolimus.   Patient was found to maintain adequate oxygen saturation on room air shortly after admission but did desaturate significantly with ambulation was thought to qualify for home oxygen.  She overall felt better shortly after admission with the use of IV fluids and supplemental oxygen.  After repeat tacrolimus level came back at 16, after discussion with the University transplant service, patient was thought to be okay to resume her tacrolimus morning of 12/24 at decreased dose of 2 mg.  Patient was also advised to consume more liquids as her renal function overall improved from a creatinine of 1.85 on admission down to a creatinine of 1.32.  As she was anxious to go home for the holidays, she was allowed to be discharged home on 12/23/2021 with repeat labs to be done on 12/27 to further evaluate her tacrolimus level.  She has also been prescribed a short course of tapering prednisone.   CONSULTS / RECOMMENDATION:  Consult Orders (From admission, onward)                IP CONSULT TO GI      Provider:         IP CONSULT TO NEPHROLOGY      Provider:            INPATIENT PROCEDURES:  Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None     BP 137/83  | Pulse 100  | Temp 36.6 °C (Oral)  | Resp 16  | Ht 1.626 m  | Wt 66.9 kg  | SpO2 94%  | BMI 25.32 kg/m²    Physical Exam General:  No acute distress Respiratory:  Clear to auscultation bilaterally with no wheezes and no use of accessory respiratory muscles  H&P: CHIEF COMPLAINT: Pneumonia due to COVID-19 virus     Assessment/Plan    ASSESSMENT / PLAN:   COVID-19 PNEUMONIA BILATERAL ACUTE KIDNEY INJURY, DEHYDRATION, DIARRHEA, REDUCED ORALLY INTAKE KIDNEY TRANSPLANT, LIVER TRANSPLANT ON IMMUNOSUPPRESSION HYPOXIA Oxygen supplementation as needed Steroids will use Solu-Medrol given the fact that she is already on chronic steroids IV hydration Monitor creatinine Check procalcitonin Antibiotics Rocephin, Zithromax given history of transplant and immunosuppression   KIDNEY TRANSPLANT Consult Nephrology Continue immunosuppressants, steroids   LIVER TRANSPLANT WITH CIRRHOSIS OF TRANSPLANTED LIVER Consult GI Lipase slightly elevated   LEFT LEG SWELLING Check leg Dopplers   HYPERTENSION Norvasc, Lopressor depending on blood pressure readings   GERD BARRETT'S ESOPHAGUS PPI   HYPERLIPIDEMIA Lipitor   DVT PROPHYLAXIS Subcu heparin   FULL CODE       Subjective    HISTORY OF PRESENT ILLNESS: Pt. is a 66 y.o. female with a past medical history of liver transplant, kidney transplant, cirrhosis, hypertension, hyperlipidemia, GERD who presents today with diarrhea and shortness of breath   Patient has not been feeling well for the 7 days.  She has been noting nausea, 2-3 episodes of diarrhea a day, reduced orally intake, generalized body aches, fatigue, sore throat, shortness of breath with exertion.  She has not had much cough or chest pain or abdominal pain.  She has been exposed to her son who has COVID-19.  She had 2 shots of COVID-19 vaccine in August 2021 and was due for her booster in February 2022. She is on prednisone for immunosuppression.    Saturating 87% on room air with ambulation, 90% on room air at rest, blood pressure 109/49 mm, COVID-19 positive, creatinine 1.84 with a baseline of 0.8, lipase 168, AST 40, ALT 26, alkaline phosphatase 168 and bilirubin 1.7, WBC 6, chest x-ray with bilateral interstitial opacities.   Patient has been given Decadron     Patient Active Problem List Diagnosis ? Status post liver transplant  ? Non-ischemic cardiomyopathy ? Hemosiderosis on liver biopsy ? Osteoporosis ? liver anastomosis ? Aortic stenosis ? stenosis portal vein ? Recurrent skin cancer ? Nuclear senile cataract of both eyes ? Hypermetropia of both eyes ? CRF (chronic renal failure), stage 4 (severe) ? CRF (chronic renal failure), stage 3 (moderate)  ? Anemia of chronic renal failure ? Acute renal failure (ARF)  ? Pancytopenia  ? Insomnia disorder related to known organic factor ? Cirrhosis of transplanted liver  ? Status post kidney transplant ? Immunosuppression  ? Severe malnutrition  ? Peripheral vascular disease, unspecified  ? Hyperparathyroidism, unspecified  ? Platelets decreased  ? Pneumonia due to COVID-19 virus ? Hypoxia Review of Systems Constitutional:  Positive for chills and fatigue. Negative for appetite change.  HENT: Positive for sore throat. Negative for ear pain, tinnitus and nosebleeds.  Eyes: Negative for eye discharge and itching.  Respiratory:  Positive for shortness of breath. Negative for cough, wheezing and chest tightness.   Cardiovascular:  Positive for leg swelling (Left lower extremity). Negative for chest pain and palpitations.  Gastrointestinal:  Positive for diarrhea. Negative for heartburn, nausea, vomiting and abdominal pain.  Genitourinary:  Negative for difficulty urinating, dysuria and hematuria.  Musculoskeletal:  Negative for back pain and joint swelling.  Neurological:  Negative for headaches, dizziness, light-headedness, seizures and tremors.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Psychiatric/Behavioral:  Negative for depression and anxiety.  Skin:  Negative for itching and rash.          Objective    OBJECTIVE: BP 110/54  | Pulse 91  | Temp 36.4 °C (Oral)  | Resp 17  | SpO2 93%    Physical Exam Vitals reviewed.  Constitutional:      Appearance: She is well-developed.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No JVD.     Trachea: No tracheal deviation.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: No wheezing or rales.  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no rebound.  Musculoskeletal:        General: No tenderness or deformity.     Cervical back: Normal range of motion and neck supple.     Right lower leg: No edema.     Left lower leg: Edema (Trace) present.  Skin:    General: Skin is warm.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.     Coordination: Coordination normal.  Psychiatric:        Mood and Affect: Mood normal.