tokens: Admission Date : 2019-06-14 Discharge Date : 2019-06-19 Date of Birth : 1968-01-21 Sex : M Service : MEDICINE Allergies : Patient recorded as having No Known Allergies to Drugs Attending : Michael A.E. Adkins , M.D. Chief Complaint : Shortness of breath , fever Major Surgical or Invasive Procedure : None History of Present Illness : Mr. Mcelveen is a 51 year-old male with metastatic RCC status post left radical nephrectomy in 2018-03-21 , status post Avastin and sorafenib , most recently on Sutent monotherapy since 2018-12-21 , with mild renal insufficiency , who presented from home on 2019-06-14 with shortness of breath and fever . Of note , he was hospitalized at Dana-Farber Cancer Institute from 9/25-10/6 with chest pain , at which time he reportedly had cardiac enzymes , an echocardiogram and a pharmacological stress test performed . It is unclear from history what these studies revealed . He reports that he felt fatigued during the week prior to the current admission . On the day of admission , he felt " congested " in his chest , and had a new fever . He was taken to the Deanna by his wife . Patrick reports a mild cough for 2 days PTA , non-productive . He denies a history of aspiration events or choking with food intake . He describes mild reflux symptoms at night . Further ROS reveals mild SOB in the days preceding admission , but he tells me that he was surprised to find out about his low oxygen saturation because he did not feel that bad . He denies chills , no chest pain , no LE swelling . In the Deanna , Tmax 102.8 , BP 100 - 140/60 s, HR 80 s, RR 20 s, Sat 75% on RA in triage , up to 100% on NRB . CXR with bibasilar consolidations . He was given Levo 750 mg PO X1 , and Flagyl 500 mg PO X1 . His BP decreased to 100 systolic despite hydration with 2L of NS . He was subsquently admitted to the ICU for further care . He was placed on Levo and Ceftriaxone . A cosyntropin stimulation test revealed cortisol 32.1 --> 36.4 . His oxygen requirement decreased , and his overall status improved quickly . He is being transferred to the floor for ongoing care . Past Medical History : 1. Metastatic renal cell carcinoma , diagnosed in 2018-03-21 , status post left radical nephrectomy at St. Margaret's Center for Women & Infants in 03/2006 . Path consistent with renal cell carcinoma of chromophobe type with Carter nuclear grade of 4/4 . Lymphovascular invasion was present . He later presented with increasing back pain , and metastatic disease was documented . He is status post Avastin plus sorafenib , protocol #04-393 , discontinued in the setting of ongoing grade III rash , involving the hands and feet in addition proteinuria secondary to the Avastin . He has been maintained on single Timlin therapy with Sutent 50 mg daily as of 2018-12-21 and has completed nearly 6 cycles . He has mild renal insufficiency in the setting of Sutent . 2. Seasonal allergies Social History : He lives at home with his wife and son , who is 7 years old . He works in real estate development and invests in stockmarket . HE is a lifelong non-smoker . Family History : Not reviewed with patient . Physical Exam : VITALS : T 96.9 , BP 110/70 , HR 84 , RR 20 , Sat 97% on 4L . GEN : In NAD . HEENT : Flushed cheeks . Slightly dry MM . NECK : JVP not elevated . RESP : Decreased air entry and crackles at both lung bases . + Egophony . CVS : RRR . Normal S1 , S2 . No S3 , S4 . No murmur or rub . GI : BS NA . Abdomen soft and non-tender . EXT : Without edema . Good pedal pulses . Pertinent Results : Laboratory results : 2019-06-14 10:30 AM BLOOD WBC - 8.0 RBC - 4.22 * Hgb - 12.9 * Hct - 41.7 MCV - 99 * MCH - 30.5 MCHC - 30.8 * RDW - 16.8 * Plt Ct - 797 *# 2019-06-19 07:20 AM BLOOD WBC - 11.1 * RBC - 3.47 * Hgb - 10.9 * Hct - 34.1 * MCV - 98 MCH - 31.3 MCHC - 31.9 RDW - 16.7 * Plt Ct - 604 * 2019-06-14 10:30 AM BLOOD PT - 11.2 PTT - 23.9 INR(PT) - 0.9 2019-06-14 10:30 AM BLOOD Plt Ct - 797 *# 2019-06-14 10:30 AM BLOOD Glucose - 134 * UreaN - 39 * Creat - 2.1 * Na - 133 K - 7.9 * Cl - 94 * HCO3 - 28 AnGap - 19 2019-06-19 07:20 AM BLOOD Glucose - 73 UreaN - 20 Creat - 1.1 Na - 136 K - 5.0 Cl - 101 HCO3 - 27 AnGap - 13 2019-06-14 10:30 AM BLOOD ALT - 34 AST - 167 * CK(CPK) - 313 * AlkPhos - 383 * Amylase - 44 TotBili - 0.7 2019-06-14 06:03 PM BLOOD CK(CPK) - 194 * 2019-06-14 10:30 AM BLOOD CK-MB - 3 cTropnT - 0.05 * 2019-06-14 06:03 PM BLOOD CK-MB -4 cTropnT - 0.03 * 2019-06-17 05:30 AM BLOOD proBNP - 258 * 2019-06-14 06:03 PM BLOOD Calcium - 8.3 * Phos - 4.3 Mg - 1.9 2019-06-18 07:55 AM BLOOD calTIBC - 229 Ferritn - GREATER TH TRF - 176 * 2019-06-16 07:35 AM BLOOD TSH - 43 * 2019-06-16 07:35 AM BLOOD Free T4 - 0.36 * 2019-06-19 07:20 AM BLOOD WBC - 11.1 * RBC - 3.47 * Hgb - 10.9 * Hct - 34.1 * MCV - 98 MCH - 31.3 MCHC - 31.9 RDW - 16.7 * Plt Ct - 604 * 2019-06-19 07:20 AM BLOOD Neuts - 77.0 * Bands - 5.0 Lymphs - 11.0 * Monos - 3.0 Eos - 0 Baso - 0 Atyps - 1.0 * Metas - 2.0 * Myelos - 1.0 * 2019-06-18 07:55 AM BLOOD PT - 11.5 INR(PT) - 1.0 2019-06-19 07:20 AM BLOOD Glucose - 73 UreaN - 20 Creat - 1.1 Na - 136 K - 5.0 Cl - 101 HCO3 - 27 AnGap - 13 2019-06-19 07:20 AM BLOOD Calcium - 8.0 * Phos - 3.3 Mg - 2.0 Relevant Imaging : 1) Bilateral LE doppler ( 06-14 ): No evidence of deep venous thrombosis in the lower extremities bilaterally . 2) Cxray ( 06-14 ): New bibasilar consolidations are demonstrated accompanied by bilateral small pleural effusion . The lung volumes are slightly increased . There is no pneumothorax identified . 3) CT Torso ( 06-17 ): 1. Marked interval enlargement of the cardiac silhouette . Together with the interval development of bilateral pleural effusions , this indicates cardiac insufficiency ( or alternatively volume overload ) and an echocardiogram may be indicated for further evaluation . 2. Bilateral basilar compressive atelectasis . Superimposed infectious consolidation is likely . 3. Interval development of tree-in-Eric nodular opacities and scattered ground glass opacities involving the right lung , concerning for an infectious process . The differential diagnosis of this is wide including viral , fungal and atypical mycobacterial infections . Drug toxicity would be a consideration , although somewhat less likely given the unilaterality of the findings . 4. New jejunal wall thickening with persistent distal ileal wall thickening and diffuse mesenteric stranding , most likely reflecting an infectious etiology . 5. Overall stability in metastatic burden . 4) ECHO ( 06-18 ): Mild symmetric left ventricular hypertrophy with preserved biventricular systolic function . Mild posterior mitral valve prolapse with mild mitral regurgitation . Small ( 0.6 cm ) circumferential pericardial effusion , largest around the left atrium . 5) L femur xray ( 06-18 ): Predominantly sclerotic lesion with interval periosteal new bone formation involving the intertrochanteric and subtrochanteric regions . No displaced fracture is demonstrated . Brief Hospital Course : Mr. Mcelveen 51 year-old male with metastatic RCC on Sutent since 2018-12-21 , admitted with fever , hypoxemia , and bibasilar pneumonia . 1) Bibasilar pneumonia : Patient was treated for community-acquired pneumonia . He was initially placed on Ceftriaxone , Levaquin , and Flagyl in the ICU but then changed to Azithromycin & CTX at time of transfer to the oncology service . He continued to have an oxygen requirement and CT scan suggested ground glass opacities , suggestive of an underlying infectious process . ECHO was done and confirmed normal ejection fraction . His respiratory status improved slowly , oxygen was weaned off , and he was discharged on course of Levaquin . 2) Metastatic RCC : Sutent was held on admission in light of acute infection . He underwent a staging CT scan torso which suggested no significant increase in tumor burden . Patient was also found to have abnormal TFTs on Sutent and was started on replacement therapy . He will need follow-up bloodwork as an outpatient . Recent CT scan showed destruction of L femoral neck . He underwent an xray of the L femur which did not suggest an acute fracture . No limitations were placed in regards to weightbearing status . Patient was instructed to restart Sutent next Monday . 3) Renal insufficiency : Creatinine improved from 2.1 to 1.3 at time of discharge . Likely related to underlying malignancy as well as prerenal component given improvement with gentle hydration . Medications on Admission : MEDICATIONS ON ADMISSION : He takes Imodium and Lomotil while on Sutent for diarrhea . He has not had a BM in 3 days now . He is also on MS Contin 45 mg PO q12 hours ( confirmed with wife ) and MSIR 15 mg every 4 hours as needed . MEDICATIONS ON TRANSFER : Heparin 5000 UNIT SC TID Albuterol 0.083% Neb Soln 1 NEB IH Q6H Ipratropium Bromide Neb 1 NEB IH Q6H CeftriaXONE 1 gm IV Q24H Levofloxacin 500 mg PO Q24H Morphine Sulfate 2-4 mg IV Q4H : PRN Docusate Sodium 100 mg PO BID Pantoprazole 40 mg PO Q24H Fluticasone Propionate 110mcg 2 PUFF IH BID Discharge Medications : 1. Levothyroxine 50 mcg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). Disp :* 30 Tablet (s)* Refills :* 2 * 2. Levofloxacin 500 mg Tablet Sig : One ( 1 ) Tablet PO Q24H ( every 24 hours ) for 4 days : last dose will be Nolen , 06-23 . Disp :* 4 Tablet (s)* Refills :* 0 * 3. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ): Take as necessary for constipation . 4. SUTENT 50 mg Capsule Sig : One ( 1 ) Capsule PO Every other day : Please restart on Wallace , 06-24 . 5. Morphine 15 mg Tablet Sig : One ( 1 ) Tablet PO Q4-6H ( every 4 to 6 hours ) as needed for Pain . Disp :* 60 Tablet (s)* Refills :* 0 * 6. Morphine 15 mg Tablet Sustained Release Sig : Three ( 3 ) Tablet Sustained Release PO Q12H ( every 12 hours ). Disp :* 90 Tablet Sustained Release (s)* Refills :* 0 * Discharge Disposition : Home Discharge Diagnosis : Primary diagnoses : 1) Pneumonia 2) Acute renal failure 3) Metastatic renal cell carcinoma 4) Hypoxemia Discharge Condition : Stable Discharge Instructions : 1) Please take all medications as listed in the discharge instructions . 2) You were admitted to the hospital and started on an antibiotic called Levaquin for a pneumonia . You should continue taking this medication and your last day will be Nolen , 06-23 . 3) When you were admitted to the hospital your Sutent was stopped . You should resume this medication starting Wallace , 06-24 . You should take this medication every other day . 4) During your hospital stay you were also found to have low thyroid hormone levels . As a result , you were started on thyroid supplements . You should have follow-up blood tests by your primary care physician B 3 months . 5) Please attend all appointments as listed below . 6) If you experience any fevers , chills , chest pain , shortness of breath , dizziness or any other concerning symptoms please return to the emergency department . Followup Instructions : 1) Provider : Yolanda Joyce , MD Phone : 337 2567 Date / Time : 2019-07-03 3:30 2) Provider : Peter Helen Braddy , MD Phone : 337 2567 Date / Time : 2019-07-03 3:30 Philip Glenn MD 60-385 Completed by : Eva Susan MD 54-940 2019-07-27 @ 1700 Signed electronically by : DR. Patrick B Santiago on : MON 2019-07-29 9:27 AM ( End of Report )