Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Blood creatine phosphokinase normal, Blood creatinine normal, Blood culture negative, Blood fibrinogen normal, Blood folate increased
Clinical narrative: 70F with met SCC of R lung, to bone/liver, most recently on gemcitabine (last C5D1 9/13) w/plan to initiate XRT, with hx of COPD (on 2-3L at baseline), recent diagnosis of A.fib (on bASA given freq falls and thrombocytopenia), multiple hospital admissions for PNA (most recently discharged from hospital on 9/28), presented with fever, found to be COVID-19+. ID following, on IV dex, abx, and remdesivir. Stable on home 3L O2. Now medically stable for discharge home after completion of full 5d course of remdesivir and cefepime.     * Pneumonia due to COVID-19 virus Hx #SCC of R lung, #COPD. Recent admission to Hospital for loculated bacterial PNA, pleural effusion, and COPD exacerbation. Was treated with abx, steroids, and thoracentesis. Following discharge felt better from a respiratory standpoint but noticed she as increasingly fatigued with non-productive cough and DOE f/b one day of fever (resolved with Tylenol). She is fully vaccinated against COVID-19 (last dose Feb, has not received booster). On adm, HDS, afebrile and stable on baseline O2 requirement of 3L. Labs notable for procal elevated to 0.29, troponin 28.  Ferritin, d-dimer and CRP high. WBC count, LFTs, Cr, LDH, ESR, CK and fibrinogen WNL. Found to be COVID-19 positive. Spike Ab positive, nucleocapsid Ab neg. S.Pneumo Ag and Legionella Ag negative. BCx NGTD. CT Chest w/ bilateral GGOs likely infectious or inflammatory etiology, small R #pleural effusion, as well as known #SCC lesion. Received cefepime/vanc in the ED along with remdesivir 200mg x1 and IV dex. ID consulted; felt not a candidate for monoclonal Ab therapy given high spike Ab. Cefepime, remdesivir, and IV dex continued. Pt completed a 5d course of cefepime (10/2-10/7), 5d course of remdesivir (10/3-10/7), and will continue dex upon discharge to complete a full 10d course (10/3-10/12).    Thrombocytopenia Presented with platelets of 140K, down from recent baseline of 240K. No bleeding gums/nose, petechiae, melena, hematuria. Of note, newly on bASA d/t new #AF, not on ppx or therapeutic AC. Exam with significant ecchymoses after recent fall as per #seizure activity but patient states this is improving. Suspect most likely etiology of her thrombocytopenia is recent chemotherapy (last 9/13), myelosuppression.   Anemia HCT 27 on admission, from recent baseline of 30-33. She is not on AC, denies any recent hematuria, melena, e/o bleeding aside from significant ecchymosis after recent fall as per #seizure activity. Reportedly with neg head CT at hospital (denied further imaging on adm). HDS. Ferritin, B12, folate and retic count elevated. Iron and TIBC and Tsat wnl. MCV >100.  Etiology likely secondary to anemia of AoC disease as well as myelosuppression from recent chemotherapy.   Seizure-like activity Reportedly had a unwitnessed fall concerning for vasovagal episode vs seizure at hospital during recent adm. Daughter states that pt got up to use commode independently despite being a fall risk due to being unable to wait any longer. Fell from commode. States that MD reported witnessed seizure activity. Seen by Neurology and went for head CT as she denied MRI brain due to claustrophobia. CT was negative for acute pathology but did show encephalomalacia in the R occipitoparietal cortical/subcortical region which they stated could function as a focus of seizures especially given her overall clinical status. Also reportedly underwent unremarkable EEG. Was started on Keppra 500mg BID. At time of discharge plan was for her to follow-up with PCP, no neuro follow-up per daughter. Patient and daughter do not feel that she had a seizure and pt stated on adm that she finds Keppra sedating. Nonetheless, we continued Keppra on adm. Again declined MRI brain her due to claustrophobia. Neurology curb-sided to discuss further. Patient tapered off keppra: 250/500 on 10/5, followed by 250 BID on 10/6, then off. Neuro to coordinate outpatient neuro f/u.   Atrial fibrillation Recently diagnosed with pAF during recent hospitalization at Holy Family. Started on diltiazem 240mg daily. AC not started due to #throbocytopenia per notes, discharged on asa 81mg only. CHADS-Vasc2 of 3. Denies history of bleeding but did have fall at hospital as per #seizure activity resulting is significant facial ecchymoses. In NSR at time of presentation, HR 80-90. Fractionated diltiazem was continued on admission. Given ecchymosis and #anemia / #thrombocytopenia after recent fall with head strike (neg CT head) favor holding off on AC at this time, especially given NSR and recent diagnosis. Continued on ASA and should f/u with outpatient cardiologist Dr. during which therapeutic AC can be discussed further.   Squamous cell carcinoma of lung, right Diagnosed 1/2020. Metastatic to bone and liver. C/b malignant pleural effusions requiring intermittent thoracenteses. Last drained during recent hospitalization at hospital the week prior to this admit. Previously on various pembrolizumab-containing regimens. PET 5/18/2021 showed increase in size of the partially necrotic lung mass, most recently on gemcitabine (last C5D1 9/13). Per 9/8 clinic note was planning to start XRT. Primary Oncologist MD; aware of admission and discharge.   Chronic obstructive pulmonary disease Chronic. On 3L NC at baseline with recent adm to outside hospital for exacerbation in setting of bacterial PNA requiring BiPAP. Received abx and steroids, clinically improved and was discharged on Augmention and steroid taper which she remained on at the time of admission (currently pred 30mg daily). On arrival, felt breathing overall improved. VBG 7.36/66 with no priors for comparison, CO2 34 up slightly from recent baseline 31. Respiratory exam reassuring, lungs CTAB comfortable on her baseline 3L via nasal canula but found to be #COVID-19 positive.   Benign essential hypertension On losartan 50mg BID and and lasix just increased from 20mg QOD to 40mg daily for HTN and lower extremity edema. No documentation of history of heart failure but no TTE on file. Also with recent fall concerning for #seizure activity. Home losartan continued. Home lasix held iso acute infection with pt net + throughout course of admission, to resume home lasix upon discharge.