Age: 10.0
Sex: M
Vaccine: COVID19
Symptoms: Respiratory viral panel, SARS-CoV-2 test negative, Sepsis, Shift to the left, Tachycardia
Clinical narrative: Admission Date: 7/16/2022  Discharge Date: 7/22/2022  Acute respiratory failure with hypoxia [J96.01] Fever, unspecified fever cause [R50.9]   HOSPITAL COURSE: Patient is a 11 y.o. male with PMHx Lennox-Gastaut, spastic CP, OSA, nephrocalcinosis, ketogenic diet, and G-tube dependence who was admitted on 7/16/2022 for acute hypoxic respiratory failure in the setting of COVID-19.    On arrival to the emergency department vital signs are obtained which reveal the patient be febrile to 38.7° C for which Tylenol was given.  He was ill-appearing on initial evaluation but in no acute distress. Patient was placed on 2 L nasal cannula and had improvement in his increased work of breathing. CMP demonstrated stable electrolytes.  Procalcitonin was not elevated.  Complete blood count was not indicative of infection other than a slight left shift.  Urinalysis was not indicative of infection.  Respiratory PCR panel was negative for RSV, influenza and covid.  Chest x-ray did not demonstrate any focal findings.  Patient was admitted to the hospitalist service for acute hypoxic respiratory failure.   On admission, patient continued to be mildly tachypneic and was kept on 0.5 L of nasal cannula.  Chest physiotherapy was scheduled for 3 times a day with hypertonic saline to be used as needed for increased secretions. Patient did become tachypneic and tachycardic when febrile but this was quickly resolved with defervesce.  Patient was restarted on his home feeds and IV fluids were discontinued.  Patient was continued on home medications.     On 7/22, the patient became persistently hypoxic, tachycardic, tachypeic, and had an increased work of breathing. He was placed on HFNC 20L/min with 40% FiO2. Xopenex therapy was started q3h. Chest physiotherapy was increased to q3h and his hypertonic saline treatments were increased in frequency to q8h. Remdesivir was started as well as 4 mg of decadron daily. Patient was made NPO when high flow. Patient did meet sepsis criteria today with tachypnea, tachycardia, fever, and a known source of infection with COVID pneumonia.   Patient's LFTs were followed while he was receiving remdesivir because he has a history of liver failure. His LFTs never indicated acute liver failure while taking remdesivir. Patient only required one day of HFNC. The next day he was weaned down to 0.5L NC. Patient was started on Pulmicort 0.5 mg BID which he will continue as an outpatient. Each day, patient's CPT, hypertonic saline therapy, and xopenex therapy were decreased in frequency because patient showed improvement in his clinical status since 7/22. Patient was started back on continuous feeds after being NPO and was slowly transitioned to his regular home feeding regimen. Patient tolerated three days of being on room air during the day. Patient does require 0.5L of oxygen while he is sleeping per his baseline. Patient received the full five day course of remdesivir before being discharged. He also received five days of decadron while hospitalized.    Patient was discharged with an asthma action plan that was created by the pulmonology team. He will continue xopenex 1.25 mg q4 during the day, HTS 3% TID, QID CPT during the day, cough assist twice a day, two more days of decadron. Patient should continue these therapies while he has increased secretions. Patient's mother can titrate his robinul at home as needed. Patient should continue his previous home medications as well. Patient's mother understands and agrees with the plan. Patient was discharged in a stable condition.