Age: 87.0
Sex: M
Vaccine: COVID19
Symptoms: Metastases to spine, Myalgia, Nucleated red cells, Osteolysis, Pathology test
Clinical narrative: Hospitalized (2.16.22 - 2.19.22); COVID-19 positive (2.16.22); fully vaccinated PLUS Booster - moderna x3 D/c Summary:Discharge Summary MD (Physician) ? ? General Medicine  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 2/16/2022 Discharge Date: Feb 19, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? Prostate cancer metastatic to lung (HCC) 02/17/2022 Unknown ? Acute respiratory failure with hypoxia (HCC) 02/16/2022 Yes ? Cancer related pain 01/28/2022 Yes ? History of CVA (cerebrovascular accident) without residual deficits 05/05/2021 Yes ? Multiple lung nodules on CT 04/19/2021 Yes ? End-stage renal disease on hemodialysis (HCC) 05/23/2017 Unknown ? Coronary artery disease involving native coronary artery of native heart without angina pectoris 10/19/2011 Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Community acquired pneumonia 02/16/2022 02/19/2022 Yes ? Chronic kidney failure, stage 5 (HCC) 11/27/2017 02/19/2022 Yes Discharge Disposition:  home health care svc    Active Issues Requiring Follow-up:  -Oncology & Palliative Care for further management of prostate cancer DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute respiratory failure with hypoxia (HCC) [J96.01]   HOSPITAL COURSE: 87 yo male with PMH of suspected metastatic cancer with unknown primary, CAD, HTN, ESRD on HD, BPH and HLD who presented to the ED with dyspnea and cough x 2 weeks. He was seen by his PCP and sent to the ED for evaluation. In the ED patient tested positive for COVID-19 with CXR demonstrating numerous bilateral pulmonary nodules suspicious for metastatic disease. He was afebrile and given a dose of Rocephin and Azithromycin by the ED and transferred to hospital due to lack of dialysis availability. He was admitted to the medicine service for acute hypoxic respiratory failure secondary to COVID-19.  # Acute Hypoxic Respiratory Failure  # COVID-19 and Postobstructive Compression of LLL Bronchus He was continued on Decadron during his stay and noted to have been fully vaccinated against COVID-19 with booster having been received on 11/11/21. Pro-calcitonin was not suggestive of bacterial infection likelihood and patient respiratory status improved with Decadron alone with noted improvement in CRP. He was weaned to room air at rest on discharge, but was requiring 1 liter with activity. Pulmonary rehab was consulted and provided home oxygen. CT thorax was obtained during his stay as part of cancer staging which demonstrated compression of left lower lobe bronchus and case was discussed with pulmonary. Given respiratory status improvement no indication for stenting.   # Metastatic Prostate Cancer Patient had a biopsy of lytic lesion of right hip (2/17/22) prior to presentation with pathology notable for adenocarcinoma and suggestive of prostate as primary. PSA was noted to be elevated and oncology was consulted. CT thorax/abd/pelvis was obtained as part of staging and oncology recommend dose of Firmagon which was administered prior to discharge. Patient was recommended to follow-up with oncology (Dr.) in 4 weeks and daughter reported palliative care had already met with patient and family prior to presentation.   CONSULTS / RECOMMENDATION: Nephrology Oncology INPATIENT PROCEDURES: None BP 144/58  | Pulse 62  | Temp 36.4 °C (Oral)  | Resp 18  | Ht 1.727 m  | Wt 77.7 kg  | SpO2 90%  | BMI 26.05 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is not toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.  Cardiovascular:     Rate and Rhythm: Normal rate.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Rhonchi present. No wheezing.  Abdominal:     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.     Hernia: A hernia is present.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert.  Psychiatric:        Mood and Affect: Mood normal.        Thought Content: Thought content normal  H&P:Date of Service:  2/16/2022  9:31 PM         Attestation signed by MD at 2/17/2022  1:27 AM   I have personally interviewed and examined the patient on     2/16/22    . Management was discussed with PA-C. I agree with the documented findings and plan of care in her note.     87 yo vaccinated man (boosted 11/11/21) with weakness, found to have Covid infection, not clear if Covid pneumonia given confounding multiple pulmonary nodules from an as yet undiagnosed but suspected malignancy. He has ESRD and does HD via left arm fistula     He was not toxic on exam, appeared to feel OK. Rales at left lung, thrill at left arm fistula, RRR.  Required 4 L nasal cannula to maintain O2 saturations greater than 91 so Decadron was started. ESRD precludes use of remdesivir.  No support for bacterial pneumonia with a normal procalcitonin despite ESRD; abx stopped.     Weaknesses current lease suspected due to COVID infection however underlying malignancy cannot be overlapped.  Biopsy collected earlier in the week pending.  CHIEF COMPLAINT ?I just got really weak? ASSESSMENT Principal Problem:   Acute respiratory failure with hypoxia (HCC) Active Problems:   Coronary artery disease involving native coronary artery of native heart without angina pectoris   Hemodialysis status (HCC)   Chronic kidney failure, stage 5 (HCC)   Multiple lung nodules on CT   History of CVA (cerebrovascular accident) without residual deficits   Cancer related pain   Community acquired pneumonia PLAN   Acute respiratory failure with hypoxia second to COVID-19 pneumonia Possible community acquired pneumonia CXR with numerous lung nodules, difficult to evaluate for acute process Currently on 4 L supplemental oxygen, does not wear oxygen at home Hemodynamically stable at this time Continuous pulse oximetry, wean oxygen as able Continue Decadron 6 mg daily Does not qualify for remdesivir given his end-stage renal disease Rocephin/azithromycin started in the ER, will continue this for now and check procalcitonin P.r.n. inhalers   Generalized weakness Likely 2nd to above in setting of chronic deconditioning PT/OT evaluations   Suspected metastatic cancer with unknown primary Numerous pulmonary and lytic bone lesions-- > awaiting pathology results from outpatient biopsy this week Pain management as needed, currently says pain is well controlled Consider palliative care consult   ESRD on hemodialysis Consult nephrology for dialysis needs Avoid nephrotoxins   Coronary artery disease Hypertension, controlled Hyperlipidemia Continue home carvedilol, statin   BPH Continue home Flomax   Diet:  Renal VTE ppx:  Heparin subcutaneous given high risk of VTE in COVID-19 positive patients as well as history of malignancy Code status:  Partial code.  He is okay with CPR, defibrillation, pressors, noninvasive ventilation.  States he would not want to be intubated.  Medical DPOA is his daughter.  HISTORY OF PRESENT ILLNESS Patient is a 87 y.o. male with medical history significant for suspected metastatic cancer unknown primary origin, coronary artery disease, hypertension, hyperlipidemia, ESRD on HD, BPH.  Presents to ER for weakness, cough, shortness of breath for 2 weeks.   Says he was feeling at baseline until 2 weeks ago, has had worsening fatigue, generalized weakness, exertional shortness of breath, cough productive of brownish sputum.  No fevers, chills, sweats, chest pain or pressure, shortness of breath at rest, orthopnea, abdominal pain, nausea, vomiting, diarrhea, leg pain or swelling, new rashes.  Had dialysis yesterday and was extremely weak following his run, could hardly walk independently.  Felt better today but after being seen by PCP, sent to ER for further evaluation.  Of note, did have biopsy of lytic lesion of right hip this week, still awaiting pathology results.  Denies known COVID-19 exposures.  Fully vaccinated with booster.  Lives in condo with wife, independent with ADLs, uses a cane for ambulation.  Former smoker, history of emphysema but does not require inhalers or oxygen at baseline.  Not on blood thinners.   In ER, vital stable.  Noted to be hypoxic and placed on supplemental oxygen.  Lab significant for known chronic kidney disease.  Found to be COVID-19 positive.  CXR significant for numerous bilateral pulmonary nodules suspicious for metastatic disease, though no clear evidence of acute process.  Started on Rocephin/azithromycin for possible community-acquired pneumonia.  IV Decadron started.  Subsequently transferred for further management.   REVIEW OF SYSTEMS Review of Systems  Constitutional: Positive for appetite change and fatigue. Negative for chills, diaphoresis and fever.  HENT: Positive for sneezing. Negative for congestion, hearing loss, sinus pressure, sinus pain, sore throat and trouble swallowing.   Eyes: Negative for pain, discharge, itching and visual disturbance.  Respiratory: Positive for cough and shortness of breath (with exertion). Negative for wheezing.   Cardiovascular: Negative for chest pain, palpitations and leg swelling.  Gastrointestinal: Negative for abdominal distention, abdominal pain, blood in stool, constipation, diarrhea, nausea and vomiting.  Endocrine: Negative for polyuria.  Genitourinary: Negative for difficulty urinating, dysuria, frequency, hematuria and urgency.  Musculoskeletal: Positive for myalgias. Negative for back pain and neck pain.  Skin: Negative for pallor and rash.  Allergic/Immunologic: Positive for immunocompromised state.  Neurological: Positive for weakness. Negative for dizziness, light-headedness, numbness and headaches.  Hematological: Does not bruise/bleed easily.  Psychiatric/Behavioral: Negative for confusion and sleep disturbance. The patient is not nervous/anxious.   OBJECTIVE BP 158/74  | Pulse 78  | Temp 36.5 °C (Oral)  | Resp 18  | Ht 1.727 m  | Wt 78.1 kg  | SpO2 94%  | BMI 26.18 kg/m²  Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is normal weight. He is not ill-appearing, toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     General: No scleral icterus.       Right eye: No discharge.        Left eye: No discharge.     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Comments: On 4 L nasal cannula, no conversational dyspnea or respiratory distress, faint crackles bilaterally at bases Chest:     Chest wall: No tenderness.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness.     Hernia: A hernia (Reducible periumbilical hernia) is present.  Musculoskeletal:        General: Tenderness ( over right ilium) present. No swelling. Normal range of motion.     Cervical back: Normal range of motion. No tenderness.     Right lower leg: No edema.     Left lower leg: No edema.     Comments: Arthritic changes of hands  Skin:    General: Skin is warm and dry.     Coloration: Skin is not jaundiced or pale.     Findings: No bruising or erythema.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.     Sensory: No sensory deficit.     Motor: No weakness.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.