Age: 69.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Hypoglycaemia, Incontinence, Lactic acidosis, Leukocytosis, Metastatic neoplasm
Clinical narrative: Patient with 2 Moderna COVID vaccinations, last dose 02/03/21, who admitted to hospital with COVID complications.  Provider discharge note below:   "70yo F with a PMH of adenocarcinoma of the gastroesophageal junction with bone metastases on chemotherapy, HTN, HLD admitted for sepsis 2/2 covid 19.   Patient presented to the ED with generalized weakness. She says she was in a fairly good state of health a couple of weeks ago, able to cook meals and do things around the house as normal. When she woke up Saturday she felt much weaker and generally not herself. She was hoping she would get better but her weakness continued to worsen. She made an appointment with her oncologist but she was unable to get in the car today on the way to the appointment, she was unable to get off the curb by herself and needed assistance. She did not fall or lose consciousness, she was just weak. She presented to the ED for evaluation. At baseline patient has no appetite. She is able to drink fluids and she denies vomiting, she just says nothing tastes good. Patient has had some ongoing exertional dyspnea but says this has worsened over the past week. She has no SOB at baseline and denies cough, fever, chest pain, palpitations. She has baseline epigastric abdominal pain, no changes. She had diarrhea from colitis a few weeks ago but this has been stable, she has on average one soft bowel movement daily. She is incontinent at baseline, she will get a cramp in her stomach and is not sure if it she is hungry, has to urinate, or has to have a bowel movement. She denies dysuria or hematuria.   Patient follows with Dr. for her cancer. She has had rash and diarrhea in the past which he suspected was immunotherapy-related toxicity with colitis, they had resolved at time of last appointment on 01/27. She had worsening diarrhea with resuming pembrolizumab. Patient was started on a trial of keytruda. She is on prednisone 10mg daily as well.    ED Course:  Vitals significant for tachycardia to 131, afebrile. Labs showed leukocytosis at 15.4, thrombocytopenia at 48, elevated creatinine at 1.2 (baseline 0.6-0.8), mild hyperkalemia at 5.4, elevated lactate at 4.5, elevated d-dimer at 8,600, tropoin 60. Covid-19 positive. CTA showed no PE but did demonstrate trace pleural effusions, ascites, soft tissue prominence at GE junction, and sclerotic lesion in T12 vertebral body.   Hospital Course:  1. Sepsis: due to proteus mirabilis bacteremia and COVID, probable underlying pyelonephritis. Pt febrile to 100.6F, intermittently tachycardic w/ leukocytosis, lactic acidosis all improved. Maintaining adequate saturation on RA. Patient was started on empiric Zosyn, later de-escalated to Keflex with improvement in symptoms. Patient to complete total of 14 days of abx tx upon d/c. Pt did not require COVID-targeted therapy   2. Generalized weakness: likely related to above. Pt is a retired OT, deferred therapy while inpatient.    3. AKI: suspect GI loss due to covid vs immunotherapy induced enterocolitis. Resolved.    4. Hyperkalemia: due to #3. Resolved    5. Thrombocytopenia: new, improving. Likely reactive. Monitor while on AC   6. Adenocarcinoma of GE junction w/ osseous mets: Follows with Dr. Received Keytruda 1/28/22 - Continue home prednisone for now    7. HTN -  Amlodipine    8. Hypoglycemia: due to lack of appetite. Resolved - Started megace    Issues Requiring Follow Up:  - Follow up w/ PCP, oncology"  As of date of submission patient has died.  She was admitted to hospice after no improvement once home, with date of death of 03/05/2022.  Her last oncology provider notes states the below:  "GE junction adenocarcinoma in a 70 YO woman who is otherwise healthy, ECOG PS1.  There was some non specific retroperitoneal adenopathy on CT abd from July 2021.  Unfortunately, PET CT from 18AUG21 shows widespread distant metastatic disease.  PD-L1 CPS scoring returned 26AUG, showing a CPS score 10-20%.  HER2 was 2+, and 5% of the tissue showed amplification, 95% did not- HER2 negative.   Counseled her and family that by imaging, her cancer is widely metastatic and no treatment would be curative.  Chemotherapy could be palliative and life prolonging.     Offered IR referral for biopsy of one of the bony lesions on PET CT, but she declined this repeatedly.     We discussed possible treatments, and given her good baseline performance status, and elevated CPS score, recommended CAPEOX + Pembrolizumab.  Started on 2SEP.     Suffered a Rash which was concerning for immune-mediated toxicity as well as diarrhea. Appears to be grade 2-3: not limiting ADLs, but relatively diffuse over ~30% BSA.  Started  40mg po daily prednisone on 16NOV21 with relatively quick taper (she weighs 54kg) and add on benadryl.  Resumed pembrolizumab at C6 but then diarrhea worsened.   Since her hospitalization last month she has declined.  At this point, her performance status at this time precludes additional chemotherapy.  Discussed this with her family, counseled them that hospice is appropriate.  Can follow up prn with medical oncology"