Age: 64.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Empyema drainage, Fatigue, Haemorrhage, Haemothorax, Hepatic enzyme increased
Clinical narrative: Hospitalized (1.17.22 - present);  COVID-19 positive (1.14.22); fully vaccinated (3 doses) ASSESSMENT / PLAN:  Patient is a 64 y.o. female with a past medical history of left breast cancer on chemotherapy presented with fatigue found to be in shock, undifferentiated requiring norepinephrine, covid-19 pna, pancytopenia, new onset afib with RVR Brief History and Medical Decision-Making: This is a 64 year old female patient with past medical hx significant for left breast cancer (stage 1A) s/p left partial mastectomy and SLNB performed on 10/4/21. She is currently receiving adjuvant chemotherapy. She recently underwent CT guided left adrenal biopsy which was complicated by hemothorax and pseudoaneurysm of left T1 intercostal artery, s/p IR embolization of T10, T11 and T12 and pleural drain placement. She was diagnosed with COVID-19 Pneumonia on 1/14/2022, she presented to ED today with feeling of generalized weakness and not feeling well. Noted to be in acute hypoxemic respiratory failure and shock requiring pressors to maintain MAP more than 65. She was also noted to be in acute kidney injury ( suspect pre-renal in etiology). In regards to the shock, the main differential currently is septic shock given neutropenia and findings on CT chest of  With increasing left sided pleural effusion that is mostly likely related to recent hemothorax and differential include empyema, She also has nodule opacities in left upper lobe. We will contine broad spectrum Abx ( cefepime and vancomycin) pending blood culture results and consult ID. We will add stress dose steroids. Obtain echo to assess for LV function and presence of pericardial effusion. Consult IR for potential drain placement in the left chest and send diagnostic samples to rule out empyema ( her platelets are low and given recent bleeding, we need to transfuse before any intervention, She might also require thoracic surgery consult). No active signs of bleeding but we will continue to follow serial Hemoglobin, anticipate the drop in hemoglobin is related to chemotherapy given findings of neutropenia and thrombocytopenia. Start Amiodarone given Atrial fibrillation with RVR on presentation. For the COVID-19 pneumonia, we will hold off on remedisivr given AKI and she is currently on stress dose steroids. Check D--dimer and obtain DVT US of both lower extremities.  Progress Note from 1.25.22: ASSESSMENT / PLAN: 64-year-old female with past medical history of left breast cancer stage IA, status post left partial mastectomy and sentinel lymph node biopsy on 10/04/2021, currently receiving adjuvant chemo with curative intent, who recently underwent CT-guided left adrenal biopsy was complicated by hemothorax and pseudoaneurysm of left T1 intercostal artery, status post IR embolization of T10, T11, and T12, with pleural drain placement.  Patient also recently diagnosed with COVID on 1/14.  Patient presented with generalized weakness and not feeling well.  Admitted to intensive care unit with shock, acute hypoxic respiratory failure. 1. Acute hypoxic respiratory failure Multifactorial in setting COVID-19 PCR, left empyema, Staph aureus pneumonia and bacteremia. Had acute tachypneic and hypoxic event on 1/24 requiring increased vent settings and further sedation. Plan: - Wean vent settings as tolerated - Lasix 40 IV qd, goal net negative  - goal O2 sat 88% and above 2. Shock - resolved - multifactorial in setting of left empyema, multifocal bilateral pneumonia, Staph aureus pneumonia and bacteremia. Plan: - Off Pressors - Solumedrol taper - 40, 30, 20, 10 per day 3. Left empyema IR placed left chest tube on 01/18.  Pleural fluid exudative with pH 6.72, glucose less than 2. IR recommended tPA / dornase. However, initially held off on tPA / dornase given recent hemothorax requiring emoblization and also pancytopenia.  CT scan of the chest 1/19 showed improving left-sided empyema, however, with minimal drainage on 1/20.  Drainage likely will be limited due to loculated infection.  - 1/20: s/p trial tPA / dornase at 1/2 dose (5 mg) x 1 on 1/20.  - 1/21: started on tPA / dornase at normal dose, plan for 5 total doses - 1/23: receiving final doses/ CXR appears well improved, no further drainage from chest tube, no signs of bleeding - 1/24: Completed tPA / dornase therapy, no immediate complications, stable and improved left lower consolidation on CXR - 1/25: significant drainage from L chest tube 355cc over last 24 hours 4. Febrile Patient became febrile during the night of 1/24-1/25. This was in the setting of recently starting Precedex and following return from IR procedure. This is likely 2/2 medication effects however superimposed new bacterial infection cannot be ruled out on exam alone. Plan: - Follow-up culturers - Discontinued Precedex - Continue to monitor temperature 5. Multifocal bilateral pneumonia Left lower lobe Staph aureus pneumonia Staph aureus bacteremia 1/18 respiratory cultures positive for MSSA, with left pleural fluid cultures positive for Staph aureus, and blood cultures positive for GPC in clusters. CT chest 1/19 (obtained for re-evaluation of left empyema) showed new multifocal pneumonia in right side, suspected to be a progression of left-sided Staph aureus pneumonia. Plan: - Escalated current abx based on repeat fever with CXR and clinical course concerning for HAP/VAP, continue Zosyn + Vanc for empiric coverage pending cultures and ID recommendations - Obtain sputum culture, if unable patient will need bronchoscopy w/ BAL - Given Staph aureus bacteremia, will need to consider future TEE for rule out infective endocarditis when stabilized - IR successfully removed R portacath evening of 1/24, will need replaced once discharged for continued chemotherapy 6. Acute systolic heart failure / heart failure with reduced ejection fraction 22% New reduced EF 22%, compared to EF 65% in 12/14/2021. Cardiology consulted, and discussed case with Cardiology Oncology, who thinks that overall less likely due to anthracycline therapy, but possible.  Patient's new reduced systolic function likely due to stress-induced cardiomyopathy in setting of shock. Plan: - could consider future repeat echo  7. Loose Stools - prolonged illness with tube feeds, unlikely to be infectious at this time, will continue to monitor temperature and for other signs of infection. Plan: - remove rectal tube as soon as possible, high risk for adverse sequela including pressure ulcers - monitor rectal tube output - follow-up C. Diff and enteric pathogens - bowel regiment changed from standing to PRN 8. Atrial fibrillation with RVR - resolved No history of atrial fibrillation, likely 2/2 shock in the setting of stress cardiomyopathy. Converted to sinus rhythm while on amiodarone drip on 1/20, has remained in sinus rhythm since. Plan: - On PO amiodarone 400mg BID, decrease dosing once received entire 10g loading dose - Patient is high risk for thromboembolic event based on CHADS-VASC2 > 3, for that reason we are starting therapeutic heparin drip - Patient also plans on receiving chemotherapy on discharge causing transient thrombocytopenia, this puts her at high risk for bleeding sequela, this issue will have to be addressed on discharge for further anticoagulation planning - plan to resume BB as able now that shock resolved  9. Pancytopenia - stable In the setting of active chemotherapy for breast cancer.  On arrival had significant neutropenia, now improved but is on stress dose steroids for shock. Hb and Plt stable. Plan: - transfuse if platelets less than 10 or less than 50 if active bleeding - transfuse if hemoglobin less than 7  10. AKI - resolved Likely prerenal in setting of shock on presentation. Based on chart review, patient has a baseline creatinine of 0.5-0.7. Plan: - patient continues to be at baseline following resuscitation - continue to trend on daily CMP 11. Elevated liver enzymes - resolved RUQ US 1/19 obtained due to gradually rising bilirubin.  Negative for biliary obstruction, cholelithiasis, cholecystitis.  Showed heterogeneous liver which may be due to hepatic steatosis.  Consider dedicated liver screening with patient more stable. 12. Metastatic breast cancer  Stage IA, status post left partial mastectomy and sentinel lymph node biopsy on 10/04/2021, currently receiving adjuvant chemo with curative intent, who recently underwent CT-guided left adrenal biopsy was complicated by hemothorax and pseudoaneurysm of left T1 intercostal artery, status post IR embolization of T10, T11, and T12, with pleural drain placement.  Plan: - holding chemotherapy pending clinical course - palliative care consult, for supportive care for husband who is patient's sole caregiver and management of chronic conditions