Age: 74.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Sinus arrhythmia, Tachycardia, Thrombectomy
Clinical narrative: Discharge Provider: DO Primary Care Provider: DO Admission Date: 2/27/2023 Discharge Date: 03/05/2023  PRESENTING PROBLEM: Bilateral pulmonary embolism Acute pulmonary embolism with acute cor pulmonale, unspecified pulmonary embolism type   HOSPITAL COURSE: Patient is 75-year-old male past medical history of BPH and smokeless tobacco use who presented to emergency department with severe shortness of breath on 02/27/2023.  Notably, he had recently started workup for left gluteal maximus mass felt to be liposarcoma outpatient.  On arrival he was significantly tachycardic with rates up into the 160s, appearing to be atrial flutter.  He did require IV diltiazem and then spontaneously converted back to normal sinus rhythm.  CTA thorax completed showing bilateral PE with right heart strain and multiple pulmonary masses.  He was started on a heparin drip.  Largest mass in the right upper lobe which is most suspicious for neoplasm.  He was additionally noted to be COVID-19 positive with symptoms starting about 1 week prior to admission.  Interventional Radiology consulted and completed mechanical thrombectomy 2/28 which removed 85-90% of clot burden with some improvement in pulmonary hypertension via PA pressures (from 40/8 (18) to 34/8 (16) mmHg).  Echocardiogram prior to thrombectomy with moderate-severe RV dysfunction and moderate dilation with systolic septal flattening consistent with RV pressure overload.  MRI of the left hip attempted to be obtained however patient unable to tolerate and exam nondiagnostic due to motion artifact.  He continued to intermittently revert back to atrial flutter, cardiology was consulted and initiated IV amiodarone once he had spontaneously converted back to NSR to maintain sinus rhythm.  He was transitioned to oral loading dose 3/4.  Hemoglobin noted to trend down after procedures with CTA abdomen and pelvis obtained to rule out retroperitoneal hemorrhage.  This demonstrated no active bleed but did show enlarging left pelvic and inguinal masses likely enlarging lymph nodes as well as a prior nodule in the right lower lobe that had grown significantly in size already suspicious for aggressive malignancy.  He did have biopsy completed of his right upper lobe mass as well as left gluteal mass in order to limit interruption of anticoagulation outpatient, this was completed 03/03/2023.  He did have very small right apical pneumothorax after the procedure which did improve with conservative management. Evaluated by Pulmonary Rehab who recommended home oxygen likely only needed with activity.  Hypoxemia is likely not related to COVID as his symptom onset was around 2/20. Steroids were not started.  He will continue 14 day amiodarone load with 400 mg twice per day then 200 mg daily and follow-up with Cardiology.  He was started on Eliquis will continue with starter pack on discharge.  Pulmonology to follow biopsy results and follow up outpatient.  Patient will need repeat echo outpatient.  Would also obtain complete blood count within the next 1 week.  Patient will need oncology referral outpatient by PCP once biopsy results are finalized.