Age: 60.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Asthenia, Blood alkaline phosphatase increased, Blood creatinine increased, Brain natriuretic peptide increased, COVID-19
Clinical narrative: 61y.o. female patient, with a past medical history of heart failure, hypothyroidism, malignant ascites, history of endometrial carcinoma peritoneal metastasis, coronary artery disease with NSTEMI history currently being treated at  gynecological oncologist. Patient presented to the EC for evaluation for ongoing abdominal pain, nausea, a diarrhea that became intolerable beginning the night of 5/21. Patient attempted use of oral antiemetics without success, patient was unable to eat or drink. Her abdominal pain also became unmanageable at home, thus her presentation for urgent evaluation. She states she was having bowl urgency with soft stool, but denies any blood in bowel movements or urine. Patient denies fevers, chills, body aches, cough, chest pain/pressure/heaviness/palpitations, shortness of breath.   Patient had a peritoneal drain placed on 4/15 which became infected, patient was treated for peritonitis related to enterococcus faecalis with IV antibiotics and discharged on PO linezolid. Patient was again recently admitted and discharged 5/17 - 5/20 for abdominal pain and leakage from old aspira drain site. On 5/18 a paracentesis was attempted but due to trace amounts of fluid, the procedure could not be completed.    Patient had initiated chemotherapy with docetaxel, carboplatin and Avastin, and was hospitalized recently for carboplatin desensitization.  During the course of hospitalization, paracentesis took place, and the patient had started to experience a new onset left-sided abdominal pain.  CT scan abdomen and pelvis was acquired, which unfortunately was suggestive of further progression of disease, especially within the liver.  Plan was to change treatment to gemcitabine and Avastin, with incorporation of Piqray.   The patient, recently initiated treatment with gemcitabine and Avastin, and received a treatment on 7/26/2022, in addition to undergoing a round of paracentesis.  The patient thereafter developed symptoms of nausea vomiting, and abdominal pain.   Patient presented to EC on 8/5 for evaluation of abd pain, chills, SOB, leg swelling, nausea, and vomiting. Patient is positive for COVID currently in isolation. Patient had paracentesis yesterday. Overall patient statess she feels about the same, denies any chest pain pressure. Patient is currently on 3L NC and stable.   1.  Nausea vomiting and abdominal pain and COVID  -As delineated above, the patient presents with concerns regarding abdominal pain, nausea and vomiting, status post paracentesis, -Overall symptoms have improved with conservative measures. -Continue adequate pain control, and antiemetics at this time. -Currently in isolation for COVID, rec'd dose 1 of remdesivir this afternoon.  -Did c/o severe itching w/o rash. Ordered hydralazine  -HGB 8.7 Plts 153  -Patient anxious and uncomfortable. States she feels confused, talking to herself, having auditory and visual hallucinations. Consulted Dr for acute delirium  -Patient states abd discomfort. Paracentesis ordered -WBC 14.2 ID following  -Creat 1.17, IV hydration, nephro consulted  -Denies any changes in shortness of breath.  -Increase in ALK phos and LFT's. Associated with remdesivir   -HGB 7.3 down 1g. Plts 353, stable. R/O hemolysis -Creat improved 1.03 from 1.17.  -Appreciate psych's recs, positive for delirium, avoid benzo use. Seroquel 12.5 3 times daily for anxiety management.  -Plan for paracentesis today -ID cleared patient for discharge -appreciate nephs recommendations. IV lasix 40mg bid, added albumin 25% 25 g  TID x 5 days. Avoid large volume paracentesis, rec's once a week.  -Appreciate medicine rec's  - continue with supportive measures, IV antiemetics -Patient is not eligible for treatment and prognosis remains very poor. Our recommendation is to transition to comfort measures only and move forward with hospice.  -Had extensive discussion with husband and patient.  -Inquired regarding home hospice. Reviewed philosophy of hospice and palliative care. Patient and husband agreeable to home hospice at this time.  -Placed stat hospice/palliative care/care management consult.  -Will discharge home pending planning and coordination of care.  -Had extensive discussion with family this morning. Overall prognosis is very poor. Patient is no longer eligible for treatment at this time. Husband was agreeable to hospice yesterday but had hesitations going home hospice due to the inability for the patient to receive as needed paracentesis. Patient overall status continues to significantly decline. At this time it is my opinion she is not eligible for ambulance transfer home for hospice. Patient was changed to no DNAR yesterday. Patient will remain inpatient until she passes.  -comfort measures only  Patient seems to be actively dying, moaning continue Robinul Dilaudid Ativan.       2.  Metastatic endometrial carcinoma: High-grade serous: Poorly differentiated: Initially FIGO 3AT3AN0M0: Current progression of disease with peritoneal carcinomatosis: Bilateral pleural effusions: -Diagnosed with high-grade serous carcinoma of endometrium: high grade serous carcinoma of the endometrium FIGO IIIa (pT3aN0M0) s/p TAH-BSO, SLND and chemotherapy with Carbo/Taxol at Karmanos, patient follows Dr GynOnc.  -High-grade poorly differentiated endometrial carcinoma initially stage Ia status post surgery March 10, 2021, subsequently got 6 cycles of carboplatinum and Taxol last cycle in August 2021 within 6 months had recurrence of pain in January and February CT showed progression and effusion.  She started on lenvatinib however significant progression.  Molecular testing has been done with Caris, no actionable mutation.  Tumor mutation burden is 3 mismatch repair stable, PD-L1 negative.  She has rare mutation RECQL4 which is not actionable at this time. -Progression of disease with peritoneal carcinomatosis and malignant ascites diagnosed 02/2022, currently on Keytruda and Lenvima.  -Patient was started on carboplatinum along with docetaxel and Avastin weekly regimen.  CT scan after completion of 2 cycles, was suggestive of progression of disease.   -Status post initiation of gemcitabine, Avastin, with possible incorporation of Piqray. -The patient is currently modest of the first cycle, status post day 1 and 8 of treatments, with subsequent treatments to be resumed upon resolution of acute events. -Patient has not started piqray due to frequent hospitalizations.  Now patient is terminal.  Actively dying.   8/7 -Patient feeling tired today, denies fevers, and remains on 3L NC.  -Some slight nausea but able to tolerate fluid and nutritional intake.  -Will continue remdesivir dose 2/5 -Spoke with patient husband, updated plan of care    8/8 -Patient continues to remain stable on 3L NC.  -Will complete remdesivir  -CBC cmp reviewed. Remains stable    8/9 -Patient anxious and uncomfortable. States she feels confused, talking to herself, having auditory and visual hallucinations. Consulted Dr for acute delirium  -Patient states abd discomfort. Paracentesis ordered -WBC 14.2 ID following  -Creat 1.17, IV hydration, nephro consulted  -Denies any changes in shortness of breath.    8/10 -Patient remains anxious and uncomfortable, has medications for anxiety -Denies and changes in respiratory status, stable on 3L NC  -HGB 7.3 down 1g. Plts 353, stable. R/O hemolysis -Creat improved 1.03 from 1.17.  -Appreciate psych's recs, positive for delirium, avoid benzo use. Seroquel 12.5 3 times daily for anxiety management.  -Plan for paracentesis today -ID cleared patient for discharge -appreciate nephs recommendations. IV lasix 40mg bid, added albumin 25% 25 g TID x 5 days. Avoid large volume paracentesis, rec's once a week.  -Appreciate medicine rec's    8/11 -Patient remains delirious, difficulty concentrating, falls asleep easily. -RRT'd this afternoon for respiratory distress, was found w/o her oxygen on. Husband updated. Patient transferred to progressive care.  -HGB <7, 1 unit PRBC's given  -Paracentesis today    8/12 -Patient doing much better since transferring to progressive care. -Patient states SOB has significantly improved  -States she does not feel ready to go home.  -CBC stable, HGB 9.2, Plts 339   8/13 -Patient seen and evaluated this AM, discussed with RN at bedside -Continue supportive measures   8/14 -Patient reports feeling nauseated this AM, IV antiemetics in place -Awaiting thoracentesis   8/15 - s/p thora.   abd hard, plan paracentesis.  - D/w ID. Dr Cannot get her off isolation , as per COVID policy yet.   - Otherwise she feels better.    8/16 -Per ID, isolation for 20 days, today is day 14.  -Family able to visit at bedside  -Acute respiratory failure, on BiPAP earlier short amount of time, with AMS. Hypercarbia, refused BiPAP.  -S/P paracentesis today 2L -Cardiac w/u this am abnormal Trops, BNP 1051.  -2D echo EF 25%, new  -Attempted left thoracentesis, fluid is loculated, attempt radiology  -S/P right throa 8/14 700 cc -CBC stable HGB 10.0, plts 346   8/17 -Had extensive discussion with husband and patient.  -Inquired regarding home hospice. Reviewed philosophy of hospice and palliative care. Patient and husband agreeable to home hospice at this time.  -Placed stat hospice/palliative care/care management consult.  -Will discharge home pending planning and coordination of care.  -Thoracentesis done today   8/18 -Had extensive discussion with family this morning. Overall prognosis is very poor. Patient is no longer eligible for treatment at this time. Husband was agreeable to hospice yesterday but had hesitations going home hospice due to the inability for the patient to receive as needed paracentesis. Patient overall status continues to significantly decline. At this time it is my opinion she is not eligible for ambulance transfer home for hospice. Patient was changed to no DNAR yesterday. Patient will remain inpatient until she passes.  -comfort measures only      8/20 Very weak fatigued, actively dying, Spent some time with the family. All family around the patient. Patient is moaning, actively dying. Continue Ativan, Dilaudid.  Robinul. Discussed with the nurse. Actively dying.     Date and time of death pronounced on  8/20/2022 at 2105.