Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Biopsy bone marrow, Blood creatinine increased, Blood culture, Blood lactic acid decreased, Blood potassium decreased
Clinical narrative: Patient currently admitted at (2) days for inpatient treatment.    H & P :  This is a 74 y.o. patient with a past medical history significant for DM type II, HTN, OSA, HLD, BLE DVT, Arthritis and Multiple Myeloma who presented to ED with symptoms of SOB, unproductive cough and Congestion. Per patient, her symptoms started on 12/1/21 and denies any sick contacts at home. In the ED, patient was found to be Covid 19 positive, with an elevated creatinine 1.7 and low potassium level 3.3. Per ED, patient was briefly hypoxic when up to the bedside commode. A CTA revealed Patchy bilateral airspace disease, concordant with COVID-19 Pneumonia, No PE and with Multifocal lytic osseous lesions, compatible with history of multiple myeloma. She was treated with IV Rocephin and Zithromax, IV fluids and Dexamethasone. Patient denies, headaches, SOB at rest, fever, night sweats, chest pain, palpitation, nausea/vomiting, abdominal pain, diarrhea/constipation, dysuria, hematuria and melena. She endorsed, however, occasional chills and a loss of taste. Patient will be admitted for further monitoring and treatment for Covid 19.   Oncology History:   1. CT angio done 08/14/2020 showed elongated expansile lytic lesion of the sternum. There are lytic lesions in the right clavicle with a pathological fracture in the right mid clavicle region. Lytic lesion in the medial aspect of the left clavicle. Lytic lesion noted left anterolateral 3rd rib and T5 vertebral body  2.  CT abdomen showed scattered small lucent lesions. A representative lesion in the posterior superior L5 vertebral body measures 1.5 cm. Lesion in the left inferior pubic ramus measures 1.0 cm. There is cortical erosion associated with this lesion. There is also some evidence of callus formation suggesting a nondisplaced pathologic fracture. A hyper attenuating nodule measuring 1.7 cm in the left perineum is unchanged since 2003  3.  Right clavicle xray showed obliquely oriented displaced mid right clavicle fracture   4. SPEP done 08/16/2020 showed monoclonal protein measuring 0.4 grams/deciliter. Immunofixation was not ordered.  5.  24 hour urine UPEP showed monoclonal protein measuring 353.6 mg/24 hours (84.4%). Total urine protein was 419 mg/24 hours  6.  Urine immunofixation consistent with kappa monoclonal free light chain.  7.  BM biopsy 9/2020:  Histologic type: Plasma cell myeloma Bone marrow cellularity: Approximately 50% Aspirate smear manual differential: 8% plasma cells Immunophenotyping (flow cytometry and/or immunohistochemistry): CD138 immunohistochemistry: 1520% plasma cells, cyclin D1 (BCL1) positive  Flow cytometry: monoclonal kappa plasma cells karyotype: 46,XX[10]  Myeloma FISH panel:  POSITIVE for trisomy 9 [66/100] (66%) POSITIVE for monosomy 13 [83/100] (83%) POSITIVE for unbalanced rearrangement of IGH@ (14q32) gene region [73/100] (73%)   8. Initial staging PET scan 9/2020: 1. Extensive findings of multiple myeloma with numerous osseous lesions demonstrating soft tissue components, mild to moderate hypermetabolism, and multiple areas of pathologic fractures some with healing callus. These lesions increase the risk of pathologic femoral fracture in a weightbearing patient. Note is made of lytic lesions involving the skull base as well as cervical and thoracic spine. 2. The left adrenal nodule has indeterminate hypermetabolism, the differential diagnosis includes atypical extraosseous involvement of myeloma versus a primary adrenal lesion. This could be evaluated with adrenal protocol CT prior to consideration of biopsy or attention on followup.  - 9/20-12/20 completed 4 Cycles of Revlimid (RVD) - 01/2021 RVD held at C5, no further maintenance RVD  Plan: Covid 19 Pneumonia Leukocytosis - Subjectively with SOB, chills, congestion since 12/1/21 - Briefly hypoxic in ED on exertion - Covid 19 positive - lactic acid 0.9 - Procal 0.54, WBC 14.8 - CRP 152.5, D-dimer 3,160 - CTA revealed Patchy bilateral airspace disease, concordant with COVID-19 PNA - Rocephin, Zithromax in ED- continue - blood cx sent after antibiotics given - s/p 1 L NS bolus - Dex started in ED-continue - IVF - Remdesivir started - ID consulted - On RA, O2 if needed - Albuterol, tessalon pearls and Robitussin prn   AKI  Pyuria Hx MDRO UTI - creatinine 1.7, baseline 0.61-1.07 - UA with Sm leukocytes, WBC 14 , moderate blood - s/p 1L NS bolus - repeat creatinine in the am - Urine Cx pending - Retroperitoneal US pending - Rocephin started in ED- continue - IVF   Multiple Myeloma without remission - Dx 9/2020 - 9/20-12/20 completed 4 Cycles of Revlimid (RVD) - 01/2021 RVD held at C5, no further maintenance RVD - Continue Acyclovir  - last monthly Zometa 11/2/21 - signed transfusion consent on the chart    Hypokalemia - on home Potassium 20 meq BID - K+ 3.3 in ED - replaced, monitor daily   HLD  - Continue home Lipitor   DM II - not on DM meds - 12/17/20 Hgb A1C 5.6 - repeat Hgb A1c pending   Hx Pathological Fracture - 8/14/20 CT chest showed elongated expansile lytic lesions of  The sternum, lytic lesions in the right clavicle with pathologic fracture in the right mid clavicle region. Lytic lesion in the medial aspect of the clavicle and, lytic lesions noted left anterolateral 3rd rib and T5 vertebral body  - PT/OT   GI Prophy - PPI   DVT prophy Hx BLE DVT - Continue home Eliquis   PARTIAL CODE/DNI Patient agreed to CPR, and declined Mechanical Intubation