Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Neutrophil count decreased, Neutrophil percentage, Nucleated red cells, Pancytopenia, Platelet count decreased
Clinical narrative: Hospitalized (1.13.22 - 1.22.22); COVID-19 positive (1.13.22); fully vaccinated PLUS Booster- pfizer x3 d/c summary:Hematology Oncology Discharge Summary BRIEF OVERVIEW: Primary Care Physician at Discharge: Medical Doctor Hematologist/Oncologist: Doctor Admission Date: 1/13/2022 Discharge Date: 01/22/2022  Problem List as of 1/22/2022 Reviewed: 2/5/2020  3:58 PM   Hospital    * (Principal) COVID-19 in immunocompromised patient    COVID-19    Unspecified severe protein-calorie malnutrition        Non-Hospital    Cervical lymphadenopathy    Follicular lymphoma grade IIIa of lymph nodes of multiple sites  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Fatigue, unspecified type COVID-19  DISCHARGE PROBLEM: COVID-19 pneumonia Failure to thrive; Adult  Low Grade Follicular Lymphoma, stage IV Pancytopenia Infrarenal AAA CKD III  COPD HTN   PRESENTING COURSE: Patient is a 72 yo male with hx of COPD, HTN, and follicular lymphoma on Gazyva presented with 2 week history of significant fatigue, anorexia, nausea, and decrease urine output. In ER he was found to be febrile and positive COVID-19 with CT chest showing COVID PNA.    HOSPITAL COURSE: He was admitted and started on Remdesivir, Decadron, and cefepime. Throughout hospitalization he needed low-dose supplemental oxygen twice. Further infectious work up remained negative. PT/OT evaluation showed need for home health PT and HHC. He was started on Remeron to assist in appetite. He completed 9 days of antibiotics and remained afebrile.    Today, he is feeling stronger. Eating better. Denies any SOB. He was educated on when to call with questions or concerns. He will will follow up on Monday for evaluation. He is stable for discharge.    CONSULTS / RECOMMENDATION: Nutrition    PROCEDURES: None      Discharge Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is well-developed. He is not ill-appearing.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist. No oral lesions.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds, S1 normal and S2 normal.  Pulmonary:     Effort: Pulmonary effort is normal. No tachypnea.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Attention and Perception: Attention normal.        Mood and Affect: Mood is depressed. Affect is blunt and flat.        Speech: Speech normal.        Behavior: Behavior is withdrawn. Behavior is cooperative.        Thought Content: Thought content normal.        Cognition and Memory: Cognition and memory normal.        Judgment: Judgment normal.  H&P:  CHIEF COMPLAINT: COVID-19 in immunocompromised patient  ASSESSMENT / PLAN: Covid 19              - Febrile in ER              - Fully vaccinated              - Positive Covid PCR              - Pt is high risk due to follicular lymphoma on Gazyva (CD20 positive B cell targeted therapy similar to Rituxan)              - CXR negative              - Fatigued, nausea, poor appetite, febrile.              - Regeneron not available, Sotrovimab only as outpatient              - Hold on Remdesivir and Decadron unless needing supplemental oxygen.               - Consider input from Pulm and ID if decompensates Febrile Illness              Felt to be Covid related              BC's x 2 obtained              Empiric Cefepime, non neutropenic dose              IVFs FTT              -14 days of progressive weakness              - Poor oral intake, per pt no meal since 01/11              - MN consult              - IVFs              - PT/OT              - Daily labs Low Grade Follicular Lymphoma              - Dx October 2016 following excisional biopsy of neck lymph node               - Considered Stage IV high grade follicular lymphoma involving liver, muscle and bone              - SP R-CHOP 2017, Achieved Complete response              - Recurrence of Low Grade Follicular Lymphoma, 02/2020              - Gazyva with Bendamustine x 6 cycles. Then solo agent Gazyva. C15 D1 given 11/23/21. C16 due 01/17/22              - Surveillance CT C/A/P is due. Pending.              - POC per doctor CKD III stable              - Cr 1.4, baseline 1.5-1.6              - IVFs              - NO ACE/ARB/NSAIDS, avoid Ct contrast and renal dose meds as able              - holding home HCTZ Hypomagnesemia              Mg 1.6 on admit              2 Gm Mg Mg sulfate given              Am labs, PRN replacement COPD              Stable              Home Symbicort and rescue albuterol HTN              Holding home HCTZ              PRN hydralazine with parameters Prophy              Heparin, hold if platelets less than 30              PPI SUBJECTIVE: This is a kind 72 yo male with hx of COPD, HTN, and follicular lymphoma. He is on Gazyva, cycle 15 11/23/21. He states he started feeling bad about 14 days ago but over the last 4 days began to have significant fatigue and no energy even to eat. He has not had a meal for 3 days. He notes decreasing urine output and nausea without emesis. He had some small loose stools yesterday, none today. He states when he gets up to ambulate he is lightheaded and is unsteady on his feet using furniture and walls to keep from falling. His wife made him go to the ER for eval. He was febrile at 38,4 in ER and Covid test returned positive. He is fully vaccinated and boosted. Subsequent CXR was negative and his vitals were otherwise stable on RA. CMP showed mildly low sodium and Cr was 1.4 but this was actually better than baseline of 1.5-1.6. He denies loss of taste or smell and denies HA. He just feels "off" and difficult to have the energy to engage. He did not think he was febrile or chilled at home.  His chemo is a CD20 B cell destroyer, and he is at high risk for poor outcomes with Covid infection. He is admitted for further work up and eval.  Empiric abx are initiated. BCs obtained.    Review of Systems  Constitutional: Positive for appetite change (severely decreased) and fatigue (profound). Negative for chills and specified pain.  HENT:   Negative for mouth sores, nosebleeds, trouble swallowing and voice change.   Eyes: Negative for eye problems and visual disturbance.  Respiratory: Negative for chest tightness, cough, dizziness on exertion, hemoptysis, shortness of breath and wheezing.   Cardiovascular: Negative for chest pain, leg swelling, palpitations and edema.  Gastrointestinal: Positive for nausea. Negative for abdominal distention, abdominal pain, constipation and vomiting.  Genitourinary: Positive for decreased urine volume. Negative for difficulty urinating, dyspareunia and frequency.   Musculoskeletal: Positive for extremity weakness (general). Negative for back pain and flank pain.  Skin: Negative for rash and wound.  Neurological: Positive for light-headedness and extremity weakness (general). Negative for headaches and speech difficulty.  Psychiatric/Behavioral: Negative for confusion and decreased concentration. The patient is not nervous/anxious.   OBJECTIVE: BP 170/83  | Pulse 87  | Temp 36.9 °C (Oral)  | Resp 24  | Wt 81.6 kg  | SpO2 94%  | BMI 25.83 kg/m²   Body surface area is 2.01 meters squared.  Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is ill-appearing.  HENT:     Nose: No congestion.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate.     Heart sounds: No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.     Comments: Diminished bibasilar, no wheeze, rub or rhonchi appreciated bilaterally apex to base, RRR on RA Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Thought Content: Thought content normal.        Judgment: Judgment normal.     Comments: Slow speech