Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Base excess, Bicytopenia, Biopsy skin abnormal, Blood alkaline phosphatase increased, Blood creatinine increased
Clinical narrative: hospital dc summary from 12/17/21 to dc on 4 Jan 2022: Anasarca, AKI on CKD III, Metabolic Alkalosis (likely due to diuresis). DDx: chronic cardio-renal injury vs TMA from gemcitabine (kidney function has been worsening progressively since the patient started it) vs interstitial nephritis from gemcitabine, Bactrim, or cephalosporins. Urine urate low, not consistent with TLS. Baseline creatinine 1.0-1.5. Creatinine on admit 2.93, today 2.45. Lasix, HCTZ, and lisinopril were held on admit. 12/17 Renal US with small bilateral kidneys, otherwise unremarkable. 12/4 Echo: EF 75%, hyperdynamic, otherwise unremarkable. 12/1 PET scan showed development of moderate sized bilateral pleural effusions, body wall edema, and lower extremity edema, compatible with volume overload. 12/17 UA with negative protein, +1 blood, +2 leukocytes, WBC 20-50, RBC 2/10, Protein/creatinine ratio 0.1. Started on a Bumex gtt at 2 mg/hr per renal, held 12/31. Received Chlorthiazide and Albumin 12/28 and 12/29. VBG (12/31) 7.46/43/44/29.7/6.2 BE/74.5 S/p IV Albumin 25g 25% x2 on 12/31 and 1/1. Nephrology consulted. S/p 1L 1/2NS @ 75 mL hr 1/4. Cr improved to 2.39 day of discharge. Continue to hold lasix, lisinopril, and HCTz at discharge. Hold bactrim ppx as well since Cr clearance <30. Follow up outpatient being arranged by nephrology.    2) Stasis dermatitis. Dermatology was consulted previously and skin biopsy was consistent with stasis dermatitis, so antibiotics were discontinued. 12/17 leg swab culture 12/17 w/ coag neg staph. Per findings are consistent with severe lower extremity edema rather than cellulitis. Would not recommend antibiotics, now signed off  For stasis dermatitis, derm has recommended triamcinolone BID x2 weeks on and 2 weeks off, restarted 1/3. Continue tylenol, tramadol, gabapentin for pain.    3) Bilateral Lower Extremity Acute DVT, Hx of DVT/PE on lifelong anticoagulation, Factor V Leiden. US of all 4 extremities obtained 12/21, bilateral upper extrem neg for acute DVT. Acute occlusive thrombus of the distal right femoral vein extending into the popliteal veins, acute occlusive and nonocclusive thrombus at the left common femoral vein and acute thrombus in the upper deep femora, upper greater saphenous, femoral and popliteal veins. Her Apixaban was stopped 12/20 w/ worsening thrombocytopenia but she had otherwise been adherent to the medication regimen. S/p Heparin gtt 12/21-12/23. IR c/s for thrombolysis, pain has improved so will hold off for now. Continue Apixaban 5 mg BID resumed 12/23. Not considered an Apixaban failure as home dose was 2.5 mg daily.     4) Cutaneous T cell lymphoma. Diagnosed in September 2020. Follows with Hematology. Recently started cycle 4 of gemcitabine on 12/10, was scheduled to get dose 12/17. Hematology consulted, continue Allopurinol for TLS ppx ( decreased to 100 mg daily duet to renal function). Chemotherapy on hold. F/u outpatient arranged.    5) Bicytopenia. Likely related to recent chemotherapy. Worsening plt 12/20-- lowest was 37-- > now 128 (12/31). Folate, B12 nml, LDH mildly elevated 541-- >661, Haptoglobin <30.  Peripheral smear w/o schistocytes, no evidence of TTP. Smear (12/27/21) with sezary cells, few schistocytes, ADAMTS13 normal. Fibrinogen 181. HIT Ab negative. Plt slowly improving.   6) Soft palate mass.  ENT consulted, noted a maxillary tori that is likely chronic, no acute intervention    7) Chronic elevated AST and Alk phos. Stable.