Age: 53.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Alanine aminotransferase normal, Angiogram pulmonary abnormal, Anion gap, Anticoagulant therapy
Clinical narrative: Hospitalized (1.3.22 - 1.7.22); COVID-19 positive (1.4.22); Vaccination status uncertain - able to verify x1 dose of Pzifer  d/c summary: Expand All Collapse All    Hematology Oncology Discharge Summary    BRIEF OVERVIEW: Primary Care Physician at Discharge Hematologist/Oncologist Admission Date: 1/4/2022 Discharge Date: 01/07/2022 Patient's Discharge Disposition:  Home in stable condition.      DETAILS OF HOSPITAL STAY:   PRESENTING PROBLEM: Dyspnea   Admission diagnoses: Narrowing of pulmonary arteries  Focal narrowing of LLL bronchus by lymphadenopathy Moderate Left pleural effusion Sepsis Presumed left lower lobe pneumonia Dyspnea New lower extremity edema Metastatic poorly differentiated carcinoma, likely renal primary A deficiency anemia Hypertension     Discharge diagnoses: Acute hypoxic respiratory failure with dyspnea improved Narrowing of pulmonary arteries Focal narrowing of left lower lobe bronchus by lymphadenopathy COVID-19 pneumonia Moderate left pleural effusion Metastatic poorly differentiated carcinoma, likely renal primary A deficiency anemia Hypertension   Procedures: S/p left thoracentesis done by Interventional pulmonology on 01/05/2022     Discharge summary:   This is a 53 yo year old patient who was admitted on 1/4/2022 with PMH of metastatic poorly differentiated carcinoma, likely renal, on Opdivo, HTN, who presented to the ED for evaluation of shortness of breath. In the ED pt met sepsis criteria with tachycardia, tachypnea, leukocytosis. A CTA thorax showed increased size of metastatic pulmonary nodules, increasing hilar and mediastinal lymphadenopathy, osseous metastases throughout thoracic spine and ribs new compared to prior studies and moderate left pleural effusion Patient was admitted to Zeeland hospital for sepsis that was felt to be due to pneumonia. He was treated with rocephin and azithromycin. Team discussed case with  Dr. who reviewed case and imaging and recommended transfer to SH BW for thora and pulmonology evaluations for possible palliative intervention. He was transferred to Hospital on 1/4/22.   Patient underwent a film array on 01/04/2022 upon admission to Hospital that was positive for COVID-19 which was not unexpected given exposure at home though apparently patient's viral load not high enough to elicit positive test result for covid 1/3/22.  Urinalysis was negative, procal was 0.35, lactate was 1.9.  Legionella and strep pneumoniae antigens were negative.  Blood cultures remain no growth to date hospitalization.  IP did thora on 1/5 with 1200 mL straw-colored pleural fluid removed.  Cultures remain no growth today and cytology was also negative.  Chest x-ray on 1/5 and 1/6 did show atelectasis.  Infectious disease team was consulted.  Patient was started on remdesivir on 1/5 though infectious disease team did not feel he needed completed remdesivir during this admission if he was otherwise stable to go home.  Patient was started on Decadron and PPI on 01/05/2022 which she will continue after discharge.  Patient was given Regeneron on 01/05/2022.  Infectious Disease team did recommend patient monitor off antibiotics the duration of this admission as well as upon discharge.  Infectious Disease team did feel that likely is dyspnea and hypoxia were not from COVID or rather related to cancer related processes. Interventional pulmonology team after having reviewed CT of thorax did feel that he likely had malignant airway obstruction but there is limited role for therapeutic bronchoscopy given the ipsilateral effusion with good relief following his thoracentesis.  They did not recommend placement of drain at this time given his active COVID infection though did recommend consideration of PleurX drain placement if pleural fluid rate can accumulate in the next 10-14 days.  Patient did require 2 L oxygen upon admission though he was weaned down to room air after thoracentesis.  Patient was evaluated by pulmonary rehab team day of discharge and did not feel he needed any oxygen at room air or with activity.  Patient still had significant dyspnea though was aware this can be expected given multifactorial reasons 1st dyspnea including cancer, effusions, and COVID.  Pulm and ID felt patient stable to DC home with close monitor of symptoms.  Patient/wife will obtain a pulse ox at home to monitor and aware to call office/911 with concerns about O2 levels.  Educated on quarantine/isolation.  Patient will continue lasix to assist in keeping effusions at bay and will have labs rechecked early this week.   Prior to discharge today, patient denies new, worsening or changes in ROS at this time, including no fevers/chills/sweats, no CP/SOB/DOE, no abd pain/N/V/D, and no neuro changes.  Patient eating/drinking/voiding well and ambulating as tolerated.  Patient will plan to follow up in our office as per below.  Patient's discharge medications were discussed and new prescriptions were sent to patient's requested pharmacy prior to discharge as per generated list below.  Patient is aware to call our office should further questions or concerns arise following this discharge.  OBJECTIVE: BP 121/90  | Pulse 103  | Temp 36.4 °C (Oral)  | Resp 16  | Ht 1.778 m  | Wt 91.9 kg  | SpO2 96% Comment: lowest sat ambulating on room air in his room | BMI 29.07 kg/m²   H&P: CHIEF COMPLAINT: Sepsis Dyspnea Pleural effusion   ASSESSMENT / PLAN:   Narrowing of pulmonary arteries  Focal narrowing of LLL bronchus by lymphadenopathy - Per CTA thorax 1/3/22 - increasing bulky mediastinal and hilar metastatic lymphadenopathy, encasing and narrowing of the left greater than right pulmonary arteries without evidence of acute embolus.  Compressive atelectasis/consolidation of LLL d/t moderate left pleural effusion and focal narrowing of LLL bronchus by lymphadenopathy  team discussed case with Dr who recommended transfer to GR for pulm evaluation of possible palliative interventions - Consult to IP pulmonology placed   Moderate Left pleural effusion - Per CTA thorax 1/3/22 - AS IP is seeing patient for above, will ask  consult for thora, send fluid for studies  - Currently 2L   Sepsis Presumed LLL PNA - Tachycardia, tachypnea, leukocytosis on presentation to Zeeland - Procal 0.35, lactic acid 1.9 - CT with compressive atelectasis/consolidation of LLL d/t moderate left pleural effusion and focal narrowing of LLL bronchus by lymphadenopathy - legionella and strep pneumo antigen neg - UA negative - Rocephin and azithromycin started at Zeeland hospital - will  - COVID-19 PCR negative 1/3/22 (recent exposure to daughter who was positive) - Blood cultures x 2 obtained at Zeeland (1/3) - pending - S/p IVF bolus - Gentle hydration given effusion             -Ck Film array   Dyspnea New LE Edema - Likely multifactorial, pleural effusion, PNA, worsening pulmonary nodules, narrowing of LLL bronchus on imaging - Thora and abx as above - EKG in ED - sinus tachycardia - BNP 731 wnl, consider echo - Lasix - Daily weights, monitor I/Os   Metastatic poorly differentiated carcinoma, likely renal primary - Diagnosed January 2021 - Mets to bones, lungs, LNs - S/p cabozantinib from 3/2021-6/2021 - S/p Lenvatinib + everolimis from 7/2021 - 11/2021 - On Opdivo since 11/2021, cycle 2 was 12/22/21 - CTA thorax 1/3/22 - increased size of metastatic pulmonary nodules, increasing hilar and mediastinal lymphadenopathy, osseous metastases throughout thoracic spine and ribs new compared to prior studies and moderate left pleural effusion - Patient of Dr., admit to Dr..    Iron deficiency anemia - S/p IV iron  - PO iron BID - Monitor   HTN - Continue home meds - Hold Hctz while on lasix   DVT prophy - lovenox   Code: Full   SUBJECTIVE: Patient is a 53 year old male with PMH significant for metastatic poorly differentiated carcinoma, likely renal, on Opdivo, HTN, who presented to the ED for evaluation of shortness of breath. In the ED pt met sepsis criteria with tachycardia, tachypnea, leukocytosis. A CTA thorax showed increased size of metastatic pulmonary nodules, increasing hilar and mediastinal lymphadenopathy, osseous metastases throughout thoracic spine and ribs new compared to prior studies and moderate left pleural effusion Patient was admitted to Zeeland hospital for sepsis that was felt to be due to pneumonia. He was treated with rocephin and azithromycin. team discussed case with  Dr. who reviewed case and imaging and recommended transfer to Hospital for thora and pulmonology evaluations for possible palliative intervention. He was transferred to Hospital on 1/4. He tells me that he does feel SOB, he has a cough. He denies any fevers or chills.      Review of Systems  Constitutional: Positive for appetite change and fatigue. Negative for chills, fever and specified pain.  HENT:   Negative for congestion, nosebleeds, rhinorrhea, sore throat and tinnitus.   Respiratory: Positive for cough.   Cardiovascular: Positive for edema. Negative for chest pain, leg swelling and palpitations.  Gastrointestinal: Negative for abdominal distention, abdominal pain, blood in stool, constipation and diarrhea.  Genitourinary: Negative for difficulty urinating, dysuria and frequency.   Musculoskeletal: Negative for arthralgias, back pain and flank pain.  Neurological: Negative for dizziness, light-headedness, numbness and paresthesias.  Psychiatric/Behavioral: Negative for behavioral problems. The patient is not nervous/anxious.   OBJECTIVE: No vitals were available at the time this note was created   There is no height or weight on file to calculate BSA.  Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: Normal appearance.  HENT:     Head: Normocephalic and atraumatic.     Nose: No congestion or rhinorrhea.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Breath sounds: No rhonchi or rales.     Comments: Occasional upper airway wheeze. Minimally conversationally dyspneic Abdominal:     General: Abdomen is flat.     Palpations: Abdomen is soft.  Musculoskeletal:        General: Swelling present.  Neurological:     Mental Status: He is alert.