Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Adenocarcinoma metastatic, Alanine aminotransferase normal, Aspartate aminotransferase increased, Biopsy rectum
Clinical narrative: Clinical Summary Assessment/Plan: Patient is a 70 year old  male with a history of recently diagnosed Metastatic NSCLC (Adenocarcinoma), COPD, Rectal ulcer 7/2022, Ulcerative Colitis, CAD, COVID-19 positive 8/3/22, who presented to hospital 8/7/22 with shortness of breath  and rectal bleeding. CXR with large R tension pneumothorax, requiring chest tube. Course complicated by diarrhea and special isolation. Planned for Home Hospice- chest tube out 8/16/22.    1.  Right  Tension Pneumothorax: presented with shortness of breath. CXR on admit with R tension pneumothorax with inferior displacement of R hemidiaphragm and slight leftward shift of cardiomediastinal structures. CTS followed with R chest tube placed in ED. Shortness of breath  improved. CXR s/p chest tube with  R PICC line, and pneumothorax resolved. Persistent air leak and thus Dr, CTS did talc treatment to R lung 8/12/2022. Post talc, CXRs with resolved pneumothorax- CTS pulled out tube 8/16/22. 2. Acute Hypoxic Respiratory Failure: In setting above and COVID-19 infection. VBG pH 7.42, pCO2 31.5, and pO2 74. CXR on admit with large R pneumothorax,  bilateral multifocal patchy nodular infiltrates and R hilar mass. Placed on 5L in ED. s/p chest tube placement with improvement. Supportive care, monitor with treatment as above. Wean for SpO2 goal 88-92%. Oral steroids.  3. COVID-19: Presented as above. Symptoms included dry cough, tested positive on 8/3/22, Vaccinated with primary series and 2 booster. Given Paxlvoid (completed  8/8/22). Did not require O2 at SNF  when first diagnosed. Given steroids in ED. CXR as discussed. De-isolated on 8/14/22 per Infection Control. 4. Elevated Cardiac Marker: BNP 3381 on admit. Trop 36 ->37. Suspect related in above setting and demand ischemia. Without chest pain, ACS unlikely. 5. Rectal Bleeding with Rectal Ulcer: Hb  8.8 on admit. Flex sig with GI at hospital on 7/14/22 with large ulcer in rectal outlet s/p biopsy. Continued to have streaking blood in stool. Suspect rectal ulcer still actively bleeding. Continued home imodium. Supportive care. Improved. 6. Ulcerative Colitis: per history. Had lot of loose BMs, stool studeis 8/9/22 negative- placed on Imodium, added Lomotil 8/10/22. GI advised CT abdomen which on 8/10/22 showed no colitis but worsening mets. Continued home Balsalazide. No role for steroids. Continue Imodium/Lomotil and supportive care. 7. Acute on Chronic Anemia: Baseline Hb  approx 11-12, admit Hb  8.8. Hb  7.7 on 6/19/22 at hospital. Suspect blood loss anemia due to rectal ulcer. Blood consent obtained 8/8/22. Monitor and transfuse for Hb  <6.5 due to shortage. 8. Elevated Liver Enzymes: On admit Alk Phos 389, AST/ALT 78/11. Mets to liver, suspect likely related. 9. Severe Protein Calorie Malnutrition: poor PO intake, decreased appetite. BMI 20.06, in setting below. Dietician following , adjust diet to patient liking. No plans for tube feeds, confirmed with daughter 8/11/2022.  10. Stage IV NSCLC: adenocarcinoma, recently diagnosed with mets to R hip, liver and brain. Follows with Oncology, Completed palliative radiation of R hip 7/8/22-7/28/22. CXR on admit with patchy nodular infiltrates b/l and R hilar mass, seen on previous CT Chest 6/7/22. Continued home Marinol and pain regimen. Family and patient agreed for hospice placement. Palliative followed. Hospice team aware; chest tube out 8/16/22. 11. Chronic Pain: in setting above. NARx reviewed. Continued home regimen. 12. COPD: Known history, Not on home O2 at baseline. No evidence of acute exacerbation. Continued home inhaler. Goal SpO2 88-92%. 13. CAD: Known history, follows with Cardiology. Continued home ASA 81 and statin. 14. Ectasis Aorta /Carotid Artery Steonsis/SMA Stenosis: per history. Follows with Cardiology. No active complaints. Continued home Betablocker and ARB for BP control. 15. CKD stage 2: per history. Cr 1.03. Follows with Nephrology. Avoid nephrotoxic agents as able. 16. BPH: per history. Continued home Flomax. 17. Pressure Injury: Coccyx pressure injury stage 3, present on admission. ET followed. 18. Code status: Status changed to DNRCCA/DNI 8/9/22 per Palliative team discussions with family. Hospice on discharge .