Age: 25.0
Sex: M
Vaccine: COVID19
Symptoms: Laboratory test, Leukocytosis, Liver function test increased, Malaise, Multimorbidity
Clinical narrative: Hospitalized for COVID (5.9.22-5.10.22);  COVID-19 positive (5.9.22);  Fully vaccinated PLUS booster BRIEF OVERVIEW: Admission Date: 5/9/2022 Discharge Date: May 10, 2022  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: COVID COVID-19  HISTORY OF PRESENT ILLNESS: Patient is a 25 y.o. male who presents today with increased work of breathing. Patient has history of developmental delay secondary to meningitis as an infant. He has resultant quadriplegia, severe CP, restrictive lung disease secondary to kyphoscoliosis, seizure disorder and dysphagia with g-tube. He resides at home with family and home nursing care requiring wheelchair, hoyer and hoyer lift. He is non verbal at baseline and therefore history is obtained from mother. Mom states that she had COVID two weeks ago. Patient started with fever on Saturday. Mother states this is abnormal for him as he usually develops hypothermia when sick. He had a home COVID test on that day, which was negative. Over the weekend, home nursing noted that he was more tachycardic with shallow respirations. Typically, pulse runs around 60, but over the weekend has been running between 100-120. He is tolerating tube feedings. Ostomy output has been at baseline. Urine output has been at baseline. His baseline is 1-6 seizures a day despite medications and mom states he is having more seizures. She has not needed nasal versed to break seizures. ASSESSMENT / PLAN: * COVID-19 Assessment & Plan Mother had COVID last week. Patient started with symptoms approximately 5 days ago. Negative home COVID test on Saturday, positive in ER 5/9/22 Vaccinated with last booster 3/2021 Patient is tachycardic with some increased work of breathing With history of asthma and restrictive lung disease, he is at high risk for respiratory decline from COVID Will admit obs with close monitoring Not requiring oxygen at this time CXR without infiltrates Initiate decadron Not candidate for remdesivir at this time. If needed, would use cautiously with history of elevated LFT Continue home nebs including pulmicort, pulmozyme, albuterol and tobramycin nebs (per infection control, patient is OK to remain in  Oxygen as needed. Typically uses 1/2 L at bedtime Lovenox for DVT prophylaxis Symptomatic treatment prn Follow labs including renal function, LFT, inflammatory labs and d-dimer   Elevated LFTs Assessment & Plan History of elevated LFT. Today's labs are improved from baseline May have elevations in LFT from COVID Monitor HOSPITAL COURSE: Pt is near baseline functional status. Father is at bedside and providing all history as patient's mental capacity is nonverbal or communicative otherwise. His lungs have significant coarse sounds with diminished BS, but they are improved after his Chest Percussion therapy. Father is wanting to start PO antiviral therapy Paxlovid, understands that's not available inpatient. Believes all current care can be provided at home as they have been doing it for many years now and are very well equipped to do so.    Readmitted to the hospital on 5.15.22 - for Sepsis secondary to UTI - still admitted currently.  HISTORY OF PRESENT ILLNESS: Patient is a 25 y.o. male with history developmental delay due to childhood meningitis, quadriplegia, restrictive lung disease secondary to kyphoscoliosis, seizure disorder, dysphagia with G-tube, and prior bowel obstruction status post ileostomy.  Patient presents from home with his mother/guardian/caretaker with concern for possible dehydration.  The patient was observed overnight and Hospital 5/9 through 5/10 for respiratory insufficiency in setting of COVID-19 infection.  Patient was vaccinated and boosted.  He is high risk due to underlying comorbidities and received PACs low vid at discharge.  He completed 4/5 days of therapy but this was stopped due to development of rash.  Patient had telemedicine appointment for COVID follow-up and was directed to the ER for hypernatremia and concern for dehydration.   In the ER, patient was transiently hypothermic to 96.3° F, borderline tachycardic with heart rate 104, tachypneic to 22 breaths per minute, but not hypotensive.  O2 sats borderline 91-93% on room air.  Labs showed stable renal function creatinine 1.0, mild chronic elevated LFTs.  Worsening leukocytosis with WBC 13, but normal lactic.  Patient flagged for sepsis and urinalysis concerning for acute urinary tract infection.  Blood cultures obtained x2.  Patient started on Levaquin and gentamicin due to cephalosporin and penicillin allergies.  He was hydrated with 1 L normal saline.  It is unclear why patient developed complicated urinary tract infection, no prior history of nephrolithiasis.  Patient was placed in observation for further evaluation and treatment complicated urinary tract infection and respiratory insufficiency in setting of COVID-19.  Discussed treatment with patient's mother, because he is within 7 day of onset, will give remdesivir for O2 sat less than 93%.  She voices agreement with plan. ASSESSMENT / PLAN:   Sepsis 2/2 complicated UTI Tachycardia, hypothermia, leukocytosis, +UA, normal lactic HR and temp improved with fluid resuscitation, warm blankets - urine cultures and sensitivities pending - blood cultures x2 pending - continue levoquin, gentamycin, started in ED (PCN and cephalosporin allergies) - renal US to r/o obstruction   Respiratory insufficiency COVID-19 infection Tested positive: 5/9, received 4 out of 5 days paxlovid (stopped 2/2 rash) Vaccinated x2 and booster on 3/2021 Observation stay at hospital 5/9-5/10, discharged home O2 sats 90-91% on room air in ED - remdesivir x5 days (within 1 week of onset) - dexamethasone 6 mg PO daily  - supplemental O2 PRN - supportive care with anti-pyretics, anti-emetics, anti-tussives, anti-diarrheal, and analgesics - consider cough assist as pt cannot participate in IS use/acapella - trend CMP, CBC, ddimer, CRP - lovenox subq for DVT ppx   Rash Suspect related to paxlovid, stopped on 5/13 Improving slightly since cessation of med - monitor