Age: 52.0
Sex: F
Vaccine: COVID19
Symptoms: Mammogram abnormal, Mean cell volume normal, Mental status changes, Metabolic function test abnormal, Metastases to bone
Clinical narrative: Hospitalized (1.21.22 - 1.26.22); COVID-19 positive (1.21.22); fully vaccinated PLUS Booster - pfizer x3.   Subsequent ED visit 1/27/22-1/28/22 (11 hrs) d/c summary from 1/26 d/c:Discharge Summary (Physician) General Medicine                                        Hospitalist Discharge Summary  Patient is a 52 y.o. female CHIEF COMPLAINT Chief Complaint Patient presents with ? WEAKNESS     lymphoma with brain mets. no current chemo/radiation. yesterday started new medication. increased confusion for months but today more weak. family says pt almost collapsed today. reports intermittent R facial droop throught cancer tx. present today but unknown for how long. family states baseline HR for pt is about 120   1. SARs pneumonia Continue treatment with dexamethasone, not on supplemental Oxygen    2. Pulmonary embolus secondary to increased viscosity due to lymphoma and SARs 2  Lovenox for 90 days plan for discharge in the next 24h.  Patient is not on supplemental oxygen.  Plan for continue treatment as outpatient.  Patient has plan for bone marrow transplant.   3. Asymptomatic bacteriuria No treatment, repeat UA was nehative    4. Diffuse large B-cell lymphoma  Patient is undergoing outpatient taper with steroids.  Patient has bone and brain Mets.  Patient is getting external beam radiation.  Patient is scheduled for bone marrow transplant February of of this year.   5. Cognitive decline Secondary to brain metastasis and brain external beam radiation due to metastatic B-cell lymphoma.  Patient is currently not undergoing chemotherapy.     6. Pancytopenia Secondary to past chemotherapy.  Bone marrow toxicity.   Summary of Hospitalization: The patient is a 54-year-old female who presented to the emergency room with increasing dyspnea on exertion fevers and shortness of breath.  The patient was worked up in emergency room found have a positive test for COVID and a pulmonary embolus.  Given the patient also has a concomitant hypercoagulable state due to COVID and lymphoma she was admitted and put on a heparin drip.  She was not requiring supplemental oxygen and did not meet criteria for treatment with remdesivir.  She had outpatient dexamethasone that was continued.  Patient was transition to Lovenox for discharge home after discussion with the oncology team.  I did partner with the patient's husband at bedside for discharge planning.  Patient has a bone marrow transplant that is planned in February of 2022 and patient will follow up per primary team.   Patient is a full code.     PRIMARY DIAGNOSIS Pulmonary embolism on left  [I26.99] Pulmonary embolism associated with COVID-19  [U07.1, I26.99]   PROBLEM LIST  Patient Active Problem List Diagnosis ? Dense breast tissue level 3 ? Enlarged  cervical lymph nodes ? Anxiety about  the development of breast ca ?  1/13/21 Abnormal ultrasound of breast  B-5  Dr App  ? Lymphoma  ? 1/23/21 BHWC Invitae ( 84 gene panel:): MUTYH One pathogenic variant   ? Diffuse large B cell lymphoma  ? DLBCL (diffuse large B cell lymphoma)  ? Gastrostomy status  ? Abnormal positron emission tomography (PET) scan ? Mass of lower outer quadrant of right breast ? 7/22/2021: Abnormal pelvic ultrasound: rec FU in 6 months ( 1/22/2022 )  ? Diffuse large B-cell lymphoma of extranodal site excluding spleen and other solid organs  ? Abnormal MRI ? Admission for chemotherapy ? Secondary malignant neoplasm of brain  ? Altered mental status ? Follicular acne ? apical HCM ? Pneumonia due to COVID-19 virus ? Pulmonary embolism without acute cor pulmonale secondary to Covid ? acute encephalopathy ? UTI (urinary tract infection) ? Pulmonary embolism on left  ? Pancytopenia  ? Facial twitching ? Cognitive impairment ? Debilitated ? Bacteriuria ? Abnormal chest x-ray BMI Body mass index is 22.13 kg/m².    CONSTITUTIONAL:  Appears well,  no pain                HEENT:   MMM, PERRLA   LUNGS: CTAB   HEART:  RRR,  S2 is greater than S1,   ABDOMEN:  Obese soft NP/ND, + BS all 4 quadrants,   MUSK:   Decreased bulk and tone, difficulty with ambulation due to falls possibly due to progression of metastatic brain disease.   NEUROLOGICAL:  Alert and oriented to person not time place or situation. Husband answers most questions   PSYCH:  Pleasant but confused   DERM: No rashes,  lesions,  petechia,  purpura,  or ecchymosis. No jaundice. Patient has thin atrophic defatted geriatric skin   I personally examined patient of privacy  on discharge. All questions were answered to the best  of my ability regarding new medications, use  and side effects.  The reason for admission, treatment, and disease were discussed with the patient.  Our discussion  also centered on medications, side effects, need for medications and the effects that they will have on his general health, teach back was performed and confirmed.  The patient acknowledged their understanding and accepts all  responsibility for obtaining prescriptions, following prescribed diet and fluid recommendations, out patient tests and follow-up   with   primary care provider or specialists  H&P:CHIEF COMPLAINT   Pulmonary embolism without acute cor pulmonale    ASSESSMENT AND PLAN Principal Problem:   Pulmonary embolism without acute cor pulmonale secondary to Covid Active Problems:   Diffuse large B cell lymphoma    Pneumonia due to COVID-19 virus   acute encephalopathy   UTI (urinary tract infection)   Pulmonary embolism on left    Pancytopenia    Facial twitching   Cognitive impairment   Debilitated _________________________________________________________   sepsis -HR>90, RR>20, WBC<4, covid 19 PNA, possible UTI -check lactic and BC x 2 -s/p 1L IVF bolus -start NSS IVF 100   covid 19 infection -immunocompromised, vaccinated and boosted, SxS began 1/20/21, husband with covid -CTA thorax showed ground glass opacities suggestive of covid 19 PNA -CXR showed RIJ port with tip in proximal right atrium, and mild to moderate airspace disease in the mid and lower lungs -ID consult, await recomendations -start decadron -check sputum culture   Acute Pulmonary embolism -CTA thorax showed acute LUL and LLL pulmonary embolism without evidence of heart strain -continue heparin ggt -continuous pulse ox   ST depression and Twave inversion, hypertrophic cardiomyopathy -cardiac MRI 1/14/21 showed possibe variant of  hypertrophic cardiomyopathy  -cardiac soft tissue 1/14/21 showed moderate amount of b/l lower lobe consolidation compatable with PNA, mild wall thickening of the distal esophagus suggestove of esophagitis -EKG showed SR with inferior and anterolateral ST depression and twave inversions and Qtc 457 -HsTnT 30--- >repeat HsTnT 30 -cardiology consult, await recomendations -telemetry   acute encphalopathy, cognitive decline and facial twitch -no focal deficits on exam -husband states pt has had progressive cognitive impairment since starting chemotherapy and radiation to her brain but is more confused today than her baseline -MRI brain with and without IVC 12/30/21 showed persistent ill-defined enhancement at the left frontoparietal junction corresponding to an area of treated brain mass -CT head negative for acute changes, positive for an area of remote hemorrhage -start neurochecks -continue home    diffuse B cell lymphoma with mets to brain -unclear if last chemo was 12/17/21 or 1/7/22, but chemo is currently on hold so pt can begin bone marrow transplant at the U of M on 2/4/22, if BMT is delayed, plan is to resume chemotherapy -continue prophylactic home acyclovir and bactrim   suspected UTI -UA with positive nitrites, moderate leukocytes, 9 WBC and bacteria -check urine Cx -continue rocephin _________________________________________________________   DVT prophylaxis -heparin ggt   Lines, Drains, Tubes, Braces -right chest port   Antibiotics, Antivirals, Antifungals -chronic acyclovir -chronic bactrim -rocephin 1/21-present   Code Status  -Full Code per discussion with pt's husband at bedside   Disposition: inpatient admission for immunocompromised pt with covid 19 PNA, acute PE, pancytopenia, EKG changes, encephalopathy, and possible UTI. check lactic and ECHO. Continue heparin ggt. Head CT showed an area of remote hemorrhage. Discussed with on call neurosurgeon Dr who recommended checking a repeat head CT once heparin is therapeutic and did not feel a neurosurgery consult was needed unless there are acute findings on repeat Head CT. ID consult and Cardiology consults. Monitor BP. Likely to stay greater than 2 midnights   SUBJECTIVE   This is a 52 y/o WF with a PMH of diffuse B cell lymphoma with brain mets s/p radiation and chemotherapy who presents with a CC of weakness x 1 day. On interview, pt does not know where she is, cannot provide history, and is pleasantly confused. she can cooperate with exam and does recognized her husband who is at bedside and provides history. Husband states the couple were running errands today when the pt became disoriented and nearly fell at curbside. he states he thinks he gave her covid because he has covid. he states they are both vaccinated and boosted. he states the pt has had a poor appetite and PO intake x 24-36 hours. he states the pt stopped chemotherapy 2 weeks ago and is scheduled to start bone marrow transplant on Februray 4th. He states the pt has had progressive cognitive impairment since starting chemotherapy and radiation to her brain but is more confused today than her baseline. He states the pt was started on Keppra for facial twitching 1 month ago. he state the pt has also had foul smelling urine x 1 month but no other urinary symptoms. he states the pt is likely constipated.   In the ER the pt was found to be afebrile with HR 130, BP 91/64, RR 22, stable on RA. limited viral PCR positive for covid 19. CBC showed WBC 3.0, Hgb 9.7, and platelets 92. CMP with Ca 8.4, albumin 2.8 otherwise WNL. BNP and procal WNL. HsTnT 30-- >repeat HstnT 30.  EKG showed SR with inferior and anterolateral ST depression and twave inversions and Qtc 457. UA with positive nitrites, moderate leukocytes, 9 WBC and bacteria. CTA thorax showed acute LUL and LLL pulmonary embolism without evidence of heart strain, and ground glass opacities suggestive of covid 19 PNA. CXR showed RIJ port with tip in proximal right atrium, and mild to moderate airspace disease in the mid and lower lungs. The pt was given rocephin, 1L IVF bolus, started on heparin ggt and admitted for workup.    Review of Systems Unable to perform ROS: mental status change   Vitals:   01/21/22 2100 01/21/22 2115 01/21/22 2130 01/21/22 2140 BP: 91/50 90/50 (!) 84/52 99/59 Pulse: 79 77 77 76 Resp: 18 17 16 17 Temp:         TempSrc:         SpO2: 98% 99% 97% 96%    Weight: Data Unavailable   Physical Exam Constitutional:      General: She is not in acute distress. HENT:     Head: Normocephalic and atraumatic.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard.     Comments: No peripheral edema Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds. No wheezing or rales.     Comments: Stable on RA Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No deformity. Normal range of motion.     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: She is alert. She is disoriented.     Cranial Nerves: No cranial nerve deficit.     Comments: Recognizes husband Unable to provide history  Psychiatric:        Behavior: Behavior normal.     Comments: Cooperative, friendly