Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Sepsis, Treatment noncompliance, White blood cell count decreased
Clinical narrative: Hospitalized (1.10.22 - 1.16.22); COVID-19 positive (1.10.22); Fully vaccinated  - moderna x2 d/c summary: Discharge Summary MD (Physician) ? ? General Medicine  BRIEF OVERVIEW: Discharge Provider:  MD Primary Care Provider: MD Admission Date: 1/10/2022 Discharge Date: 01/16/2022    Active Hospital Problems   Diagnosis Date Noted POA ? Pneumonia due to COVID-19 virus 01/16/2022 Clinically Undetermined ? Pneumonia due to influenza 01/16/2022 Clinically Undetermined ? Alcohol use disorder, moderate, dependence  01/16/2022 Yes ? Large pleural effusion 01/10/2022  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Essential hypertension  Recurrent pleural effusion on right  Malignant neoplasm of right lung, unspecified part of lung  Pneumonia of right lower lobe due to infectious organism  Large pleural effusion    HOSPITAL COURSE: 68-year-old male with history of stage III lung adenocarcinoma status post chemoradiation, recurrent pleural effusion, recent pericardial effusion status post drainage, anemia, alcohol abuse, radiation pneumonitis, non-insulin-dependent type 2 diabetes, hypertension presents with shortness of breath and fever found to have recurrent right pleural effusion.  Patient has had multiple admissions for recurrent pleural effusion recently.  Most recently he was admitted for an enlarging pericardial effusion status post pericardiocentesis with drain placed.  Serial echos have been reassuring and shortness of breath and chest pain resolved.  Patient was to have follow-up with interventional pulmonology for assessment possible pleural drain versus pleurodesis.  He came to emergency department with increasing chest pain and shortness of breath.  Chest x-ray showed recurrent right pleural effusion.  Patient was placed on Unasyn.  IR was consulted for thoracentesis.  Pulmonology was also consulted.   Patient underwent thoracentesis on 01/11.  Cultures remained no growth and cytology returned negative.  Pulmonology discussed medical thoracoscopy and PleurX versus pleurodesis however the patient declined intervention. Due to ongoing shortness of breath and fever film array was obtained and was positive for covid-19 and influenza. He completed 5 days of antibiotics, which were then discontinued as bacterial pneumonia was felt unlikely. The monocolonal antibody team was contacted however no MAB was available for inpatients. Repeat limited echo was negative for recurrent pericardial effusion. Repeat CXR after thoracentesis was negative for re-accumulation of the patient's pleural effusion.  His colchicine was continued for his recent pericarditis/pericardial effusion. His cough and congestion was treated symptomatically.    Throughout his stay the patient remained frustrated and declined much of his care including labs and pulse oximetry monitoring. He minimally engaged with nursing staff and the clinical team and would answer very few questions despite multiple attempt to explain his clinical condition and options for symptomatic and therapeutic treatment. He remained hemodynamically stable and on room air, without infiltrates to suggest pulmonary inflammation due to covid, thus he was not treated with steroids. He was discharged in stable condition to complete isolation at isolation facility (through 1/21 if symptoms improved). Followup information was provided for the pulmonary clinic if he were to wish to pursue procedural intervention for investigation and treatment of his pleural effusion.   CONSULTS / RECOMMENDATION: Consult Orders (From admission, onward)                IP CONSULT TO PULMONOLOGY      Provider:   MD          INPATIENT PROCEDURES: BP 135/71  | Pulse 106  | Temp 37.1 °C (Oral)  | Resp 16  | Ht 1.803 m  | Wt 88 kg  | SpO2 97%  | BMI 27.07 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is not toxic-appearing.  HENT:     Head: Normocephalic and atraumatic.     Nose: No congestion.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General: No scleral icterus.    Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Rhonchi present. No wheezing or rales.  Abdominal:     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: No swelling.     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert. Mental status is at baseline.   H&P: CHIEF COMPLAINT: Large pleural effusion   ASSESSMENT/PLAN:   Patient is a 68 y.o. male presenting with Large pleural effusion.   Suspected Complicated Community Acquired Pneumonia, Sepsis Recurrent Right Pleural Effusion - suspect malignant vs parapneumonic Acute hypoxic respiratory insufficiency History of Radiation Pneumonitis Has had multiple thoracenteses performed over the past few months and has recently been reaccumulating quite quickly, cytology has thus far been negative.  Recent CTA was negative for PE. Consult Pulmonology to further discuss pleural drain verses pleurodesis, he was to follow-up with them as an outpatient for this IR consulted for repeat thoracentesis orders include infectious labs and cytology Unasyn started Continue PO lasix started during last admission Pulse ox Film array pending Supportive care with Tessalon Perles, p.r.n. albuterol, guaifenesin IS   Stage III Lung Adenocarcinoma Diagnosed 09/2020, no extrathoracic metastasis.  Underwent 7 rounds of chemo with carboplatin and Taxol completed 12/30/2020 as well as chest radiation completed 01/12/2021.  Previously followed with Dr. and Dr., but was lost to follow up.  Now following with Oncology. Recent CTA without clear evidence of recurrence Thoracentesis with cytology pending   Pericarditis - thought to be due to a virus Pericardial effusion Patient recently seen by Cardiology status post pericardial drain Continue ibuprofen through 1/12 and continue colchicine for three months from initial diagnosis Limited echo given recurrence of shortness of breath and chest pain   NIDDM2 Diabetic diet 24 hour corrective insulin   Deficiency anemia Seen by hematology during his previous visit Status post IV iron on 12/29, no further IV iron planned Daily complete blood count   Alcohol Use Disorder Folate, B12, thiamine, multivitamin supplement MSW consult for alcohol cessation    Hypertension Continue home lisinopril, amlodipine   BPH Continue home Flomax   GERD Continue PPI   Code: Full DVT ppx: Early and progressive mobility Diet: Diabetic    MD Hospitalist, Internal Medicine         HISTORY OF PRESENT ILLNESS:   Patient is a 68 y.o. male with a past medical history of stage III lung adenocarcinoma diagnosed in 09/2020 status post chemotherapy and radiation with port still in place follows with Oncology, recurrent pleural effusion, recent pericardial effusion and status post drainage, anemia, EtOH abuse, radiation pneumonitis, BPH, non-insulin-dependent type 2 diabetes, hypertension who presents with shortness of breath and fever found to have recurrent right pleural effusion.  He has had a complex recent past medical history with several hospitalizations emergency department visits for chest pain and shortness of breath. Patient continues to be noncompliant with outpatient care and has not been taking his medications.   In December, he was evaluated for potential pericarditis with pericardial effusion, and was treated with colchicine and ibuprofen. He was admitted 12/22 through 12/24 for pericarditis and pericardial effusion as well as recurrent right pleural effusion, echo at that time showed a normal EF, effusion, and no tamponade, thoracentesis was done at that time and cytology was negative. Admitted again 12/26-12/27, CTA thorax with no PE but initially was concerning for tamponade, on echo no tamponade so colchicine and ibuprofen for pericarditis was continued per Cardiology, and received thoracentesis again.  He was also noted to have acute on chronic anemia and AKI, but refused further workup and left AMA.  He was again admitted 12/28 through 1/3 with enlarging pericardial effusion, cardiology performed pericardiocentesis and a drain was placed, serial echoes reassuring and his shortness of breath and chest pain resolved.  Outpatient follow-up with Interventional pulmonology was arranged to reassess need for further interventions with pleural drain versus pleurodesis.   He re-presented today with chest pain and shortness of breath   Prior physician notes, labs, imaging reviewed.   Patient Active Problem List Diagnosis ? Adenocarcinoma of lung, stage 3, unspecified laterality  ? History of tobacco use ? History of pancreatitis ? Cerebrovascular disease ? Elevated alpha fetoprotein ? Normochromic normocytic anemia ? Mediastinal lymphadenopathy ? Alcohol use disorder, mild, abuse ? Radiation pneumonitis  ? BPH (benign prostatic hyperplasia) ? Diabetes mellitus type 2, diet-controlled  ? HTN, goal below 130/80 ? Port-A-Cath in place ? Hepatic steatosis ? Splenomegaly ? Pleural effusion ? Large pleural effusion Review of Systems: Review of Systems Constitutional:  Positive for fever. Negative for fatigue.  HENT: Positive for sore throat. Negative for trouble swallowing.  Eyes: Positive for itching.  Respiratory:  Positive for cough and shortness of breath.   Cardiovascular:  Positive for chest pain.  Gastrointestinal:  Positive for diarrhea. Negative for nausea, vomiting, abdominal pain, constipation and trouble swallowing.  Genitourinary:  Negative for difficulty urinating and dysuria.  Musculoskeletal:  Positive for edema. Negative for joint swelling.  Neurological:  Negative for headaches and weakness.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Psychiatric/Behavioral:  Negative for sleep disturbance.  Skin:  Negative for rash and wound.      OBJECTIVE:   BP 122/60  | Pulse 106  | Temp 37.6 °C (Oral)  | Resp 26  | SpO2 100%  Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed. He is not diaphoretic.     Comments: Laying in bed, appears conversationally dyspneic but comfortable  HENT:     Head: Normocephalic and atraumatic.  Eyes:     General: No scleral icterus.       Right eye: No discharge.        Left eye: No discharge.  Neck:     Trachea: No tracheal deviation.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard. No friction rub. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No stridor. No wheezing or rales.     Comments: Decreased breath sounds on the right Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:     Cervical back: Neck supple.     Comments: 1+ BLE edema  Skin:    General: Skin is warm and dry.     Findings: No erythema or rash.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Behavior: Behavior normal