Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: Malnutrition, Metabolic encephalopathy, Neutropenia, Neutrophil count decreased, Pain
Clinical narrative: Patient is a 59 y.o. female with a history of Intestinal T cell lymphoma (on Alemtuzumab) and extensive intra-abdominal surgical hx including recent SBO s/p SBR (4/25/23) complicated by anastomotic leak (IR drain removed 8/15/23) who presented to hospital 8/17/23 with abdominal pain, dyspnea and weakness. CT AP showed dilated distal duodenum and jejunal anastomosis concerning for possible anastomotic stricture in addition to mild enteritis. COVID PCR (+). Additionally found to have C. Diff and pseudomonas UTI. Hospital course complicated by poor PO intake, encephalopathy, and GOC discussion. Patient was ultimately discharged to LTC with hospice as DNRCC after COVID isolation complete 9/6/23.   1. Acute on chronic Leukopenia, Neutropenia: WBC 710, ANC 550 (recent baseline 3K/2.8K respectively). Known cancer on Alemtuzumab and with COVID. No fevers since admit. UTI suspected as below. Continued home suppressive valganciclovir, held bactrim. Completed filgrastim. BMT followed. Improved prior to discontinuation of labs. Discharged as DNRCC on hospice.  2. Malnutrition/Cachexia POA: severe per ASPEN criteria, POA. Secondary to chronic and acute illnesses. No PO intake this admission due to pain. PEG tube placed previously but patient previously declined tube feeds. Peg feeds continued. Nutrition followed. Palliative followed, GOC discussion 8/29/23, LTC w/ hospice. 3. Acute UTI: UA large LE and many bacteria. Urine cultures gew pseudomonas. Completed cefepime 8/23/23. Patient again reported dysuria on 9/6/23, foley catheter replaced and straight cath urine infectious appearing. Discussed possibility of incomplete treatment with ongoing foley, son agreeable to course of abx and phenazopyridine. 4. Hypotensive Episodes: intermittently though pt remains asymptomatic and Afeb and no clinical indicators for infectioius work up so likely due to poor intake. MIVF and Bolus IVF PRN. S/p 50mg of IV albumin on 9/2/23 overnight with improved BP. Resolved. Resumed home midodrine on discharge. 5. Acute metabolic encephalopathy: noted 8/20/23. No focal deficits. Suspected related to acute illnesses/malnutrition. 8/17/23 CT head with remote infarcts but no acute findings. Worsened, 8/28/23 with repeat CT head nonacute. Stable. 6. COVID-19 positive: Tested positive 8/17/23. CT AP showed nodule consolidation of posterior RLL No gas exchange impairment or significant symptoms. Continued dexamethasone per BMT recommendations. Completed remdesevir 8/25/23. Isolation discontinued 9/6/23. 7. Concern for anastomotic stricture: Hx of mid-jejunal stricturoplasty in 12/2022 at another hospital. Recent percutaneous drainage catheter near this area removed outpatient 8/15/23. CT AP showed dilation of distal duodenum and jejunal anastomosis concerning for anastomotic stricture. SBFT without obvious obstruction but possible minimal stricture. GT to straight drain. General surgery followed: no acute surgical intervention needed. 8. Acute EBV: EBV DNA positive on 8/18/23. Supportive care.  9. C.Diff enteritis: POA, Tested positive 8/19/23. Completed PO vanc on  8/28/23.  10. Intestinal T cell lymphoma: per hx. Follows with BMT. Completed 12 week course of campath. Completed filgrastim, BMT followed. Held alemtuzumab. 11. Chronic pain: secondary to cancer. Continued home PO dilaudid. Discontinued oxycodone due to risk of respiratory suppression/sedation. 12. Chronic anemia: Hgb 7.4 on admit (baseline 8-9) likely related to BM suppression from cancer / chemotherapy. Stable. Monitor. 13. COPD: Stable on admit. Continued home inhaler regimen. 14. Mood disorder: Stable on admit. Continued home regimen