Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Vertebral wedging, White blood cell count increased
Clinical narrative: Patient received COVID vaccine on 6/9/21, tested COVID positive 8/6/21 (tested negative for COVID on 7/2/21, 8/16/21, and 8/17/21)  8/5/21: Patient is a 59 y.o. female with past medical history significant for Type II diabetes mellitus, essential hypertension, and known spinal lytic lesions who presented to the ED yesterday for chief complaint of worsening lower back pain. She reports that her pain has progressively impeded her ability to ambulate and complete simple ADL's in the past few weeks. She reports new numbness to her right hip, however denies loss of bladder or bowel control, recent falls, or any other acute complaints today. Of note, the patient was admitted on 7/16 with concern for spinal lesion found. An MR spine was completed, showing 10mm nodule in right superior medial posterior breast and lytic destructive lesion within the L1 vertebral body, right superior portion of T12, as well as large omental deposit. An MRI showed cord and thecal sac compression at this time, prompting ortho, neurosurgery, and IR guided biopsy that was significant for malignant metastatic adenocarcinoma with high suspicion of breast primary site. She was subsequently discharged and mammography guided biopsy of her left breast was completed on 7/28 with pathologic results pending. Workup thus far in the ED has been significant for UTI, elevated CRP, sed rate, MRI with stable findings with exception of re-demonstration of L1 lytic lesion with worsening wedge deformity suggestive of new pathologic fracture. There is additional extensive enhancement throughout the subdural space throughout the thoracic spine, resulting in mass-effect and deformity of portions of the spinal cord. Hospital medicine has thus been consulted for admission of this patient for further management of her symptoms.   Patient is a 59 y.o. female with past medical history significant for Type II diabetes mellitus, essential hypertension, and known spinal lytic lesions who presented to the ED yesterday for chief complaint of worsening lower back pain.   1. L1 lytic lesion concerning for malignant metastases with suspected breast primary malignancy - FNA of lumbar spine lesion last month significant for malignant metastatic adenocarcinoma with high suspicion of breast primary site - CT spine shows stable 9mm lytic lesion in T12 vertebral body with no new acute pathologic fracture seen. Extensive multilevel degenerative changes with prominent endplate and similar appearing Schmorl's nodes - Re-demonstration of L1 2.4 cm lytic lesion with worsening wedge deformity suggestive of new pathologic fracture. No acute lytic lesion or fracture identified within the remaining lumbar vertebrae - Extensive enhancement throughout the subdural space throughout the thoracic spine, resulting in mass-effect and deformity of portions of the spinal cord. - Dermatome pattern of numbness consistent with L1 involvement  - Mammogram completed on 7/28 with results significant for right breast Bi-RADS 4 suspicious finding. Biopsy results pending.  - ED has consulted ortho spine with recommendations pending  PLAN - Follow up on ortho spine recommendations  - Will initiate dexamethasone 4mg Q6 hours for symptomatic relief  - Pain control with oxycodone, PRN morphine for now  - PT/OT evaluation ordered and pending    2. Urinary tract infection - UA significant for 100 protein, small bilirubin, trace ketones, 2.0 urobilogen, trace leukocytes, negative nitrites, 6-10 WBC, calcium oxalate crystals, and present bacteria.  - No evidence of renal calculi on CT abdomen  - Sed rate >111, CRP 163.8, WBC: 10.84 - Patient denies current symptoms including dysuria, hematuria, or urinary frequency  PLAN - Start empiric rocephin for now given signs of infection ; discontinue as indicated  - Urine culture ordered and pending collection   3. Type II Diabetes Mellitus with hyperglycemia  - Poorly controlled; patient A1C 1 month ago 7.8 - Home regimen includes metformin - High glucose today of 151 PLAN -FSBG ACHS -SSI not indicated at this time given stable BG; initiate if changes -Hold patient metformin, PO antihyperglycemic medications until discharge.   4. Essential hypertension  - Patient has been normotensive while at the ED with high BP of 133/81 - Home medications include lisinopril-hctz PLAN - Continue to monitor vital signs and trend BP  - Hold outpatient antihypertensives for now; restart as indicated  - PRN IV antihypertensives for SBP sustained > 180   5. Hypercholesterolemia  PLAN - Continue outpatient pravastatin  9. Morbid obesity (POA) - BMI on admission is: 40.72 - complicates multiple aspects of the patient's care PLAN - Diet and exercise counseling to be provided before discharge  8/28/21 Discharge Summary:    Admission Date: 8/5/2021     Discharge Date:  08/29/21   Primary Discharge Diagnosis Spinal cord compression due to malignant neoplasm metastatic to spine (CMS/HCC)    Secondary Discharge Diagnosis Patient Active Problem List Diagnosis ? Type 2 diabetes mellitus, without long-term current use of insulin (CMS/HCC) ? High cholesterol ? Metastasis to vertebral column of unknown origin (CMS/HCC) ? Closed fracture of first lumbar vertebra (CMS/HCC) ? Morbid obesity (CMS/HCC) ? Cancer associated pain ? Hypothyroidism ? Acute respiratory failure with hypoxia (CMS/HCC) ? Malignant ascites ? Urinary retention ? Spinal cord compression due to malignant neoplasm metastatic to spine (CMS/HCC) ? Peritoneal carcinomatosis (CMS/HCC)     Discharge Disposition Home with home health vs. Hospice    Outpatient Follow-Up     Test Results Pending at Discharge Pending Labs    Order Current Status   Body Fluid Cell Count W/O Diff - Ascities Collected (08/26/21 1823)   CBC and differential Collected (08/11/21 0544)   Comprehensive metabolic panel Collected (08/11/21 0544)   Fine needle aspiration - Core Biopsy Collected (08/26/21 1816)   Cytology - Ascites In process   Urine Culture In process   AFB Culture, Non Respiratory Source and Acid Fast Stain Preliminary result   Fungal Culture, Sterile Body Fluid (NOT CSF) and KOH Preliminary result         DETAILS OF HOSPITAL STAY   Presenting Problem/History of Present Illness Urinary retention [R33.9] Metastasis to vertebral column of unknown origin (CMS/HCC) [C79.51, C80.1] Closed fracture of first lumbar vertebra, unspecified fracture morphology, initial encounter (CMS/HCC) [S32.019A]   Hospital Course Prior to this admission:  Patient was admitted on 7/16/2021 with concern for spinal lesion found. An MR spine was completed, showing 10mm nodule in right superior medial posterior breast and lytic destructive lesion within the L1 vertebral body, right superior portion of T12, as well as large omental deposit. An MRI showed cord and thecal sac compression at this time, prompting ortho, neurosurgery, and IR guided biopsy of L7 that was significant for malignant metastatic adenocarcinoma with high suspicion of breast primary site as was ER+/PR+.  She was subsequently discharged and mammography guided biopsy of her left breast was completed on 7/28/2021 showing fibroadenoma.    Patient is a 59 y.o. female with history of T2DM, metatstatic carcinoma of unknown primary who presented to the emergency department on 8/6/2021 with progressive back pain and imaging concerning for progression of malignancy into spine, found to be COVID positive.    On 8/6 she presented with new onset urinary retention with worsened lower back pain. MR of the L spine showed enhancement in the L1 vertebral body (concerning for metastatic disease) as well as compression on the thecal sac and cauda equina. She was admitted to medicine. Neurosurgery was consulted who had no acute surgical intervention to offer. Patient was initiated on dexamethasone as well as remdesivir for COVID-19 infection.     Oncology was consulted on 8/10 and recommended initiation of anastrozole and continuation of dexamethasone for cord compression. Radiation oncology was consulted on 8/20 and performed palliative radiation therapy.    Overall patient's functional status is very poor. Throughout her entire 23 day hospitalization she was unable to participate in care, unable to walk or urinate without a catheter secondary to her advanced disease. She was evaluated several times by physical therapy who recommended she be discharged to a rehabilitation facility, however she and her family declined. Patient and family's goal is to return home, however they were also not ready to make a transition to hospice prior to discharge until additional evaluation could be performed. Her symptoms are concerning for ongoing spinal cord compression, this was expressed to the patient and her family who still requested discharge home. Prior to discharge they planned to either follow-up with oncology in 1 week or transition to hospice once home. Resources provided for the hospice agency in their home county.    Please see below for a problem based hospital course:    Spinal Cord Compression secondary to metastatic malignancy  Urinary Retention likely secondary to continued spinal cord compression  - Presented with urinary retention, imaging with compression of cauda equina  - Neurosurgery and ortho spine consulted, no operative management to offer  - Foley placed on admission and treatment initiated for cord compression with dexamethasone, now status post palliative radiation  - Voiding trial of 12hrs failed prior to discharge and foley was replaced. Discussed risks related to chronic indwelling foley catheter with patient and daughter as well as likely underlying cause. They requested discharge home.  PLAN:  - Discharged home with indwelling foley: If decision is made to transition to hospice, hospice will manage catheter. Will followup with PCP or oncology otherwise, daughter expressed understanding of etiology and plan  - Dexamethasone 2mg daily continued at discharge    Carcinoma metastatic to spine, axial skeleton and peritoneum (ER/PR positive AdenoCA) | Unproven primary  - Biopsy at L7 (July 2021): metastatic carcinoma ER+/PR+ - Biopsy of breast mass (July 2021): fibroadenoma  - Lumbar puncture with IR on 8/9/2021 without cells for cytology  - Oncology consulted who recommended initiation of anastrozole, continuation of dexamethasone and further investigation for primary  - CT A/P on 8/19 showed worsened peritoneal carcinomatosis. Surgical Oncology consulted for omental biopsy, however discussions with surgical oncology were discordant with conversations previously had with oncology regarding prognosis if this is truly metastatic breast cancer. If breast is true primary or if HER2 status can be delineated she would likely be candidate for hormonal therapy leading to improved quality of life. Surgical Oncology signed off. Planned to biopsy vertebral lesion 8/26 however patient did not tolerate positioning.  PLAN:  - Workup remaining includes obtaining tissue for HER2 testing, patient to followup with oncology if desired  - Continue use of TSLO if attempts at ambulation made  - Continuing anastrozole, dexamethasone    Malignant Ascites  - Required therapeutic paracentesis on 8/12, (4.9L removed, cytology positive for malignancy) and 8/26 (5.5L removed, cytology pending)  PLAN:  - Will need continued large volume paracentesis approximately every 2 weeks, will be set up via oncology or hospice (Patient to establish with Hospice, can perform in patient's home)    Cancer-related pain - Patient underwent palliative radiation on 8/20, 8/21  - Palliative care consulted while inpatient to assist in pain regimen creation, prior to discharge adequate pain control had been achieved  PLAN:  - discharged with one week supply of Extended release morphine, 30mg BID, oxycodone 5mg q4 PRN and gabapentin  - Hospice vs. Oncology will take responsibility of these medications    Intermittent Hypotension - Patient had several episodes of asymptomatic, fluid responsive hypotension  - Critical care consulted and recommended bolusing PRN - Lactate, urine output all within normal limits during these episodes  - etiology could be secondary to progression of malignancy, infiltration of adrenal glands  - patient declined invasive investigation or treatment that might delay her discharge home  PLAN:  - previous home antihypertensives held at discharge    Depression  - Psychiatry consulted during this admission  PLAN:  - continue venlafaxine at 75mg daily, mirtazapine 7.5mg at bedtime    Acute respiratory failure with hypoxia | COVID-19: RESOLVED  Bilateral pleural effusions in setting of malignant ascites  - Patient COVID-19 Positive on admission, received dexamethasone and remdesivir  PLAN:  - will discharge home with supplemental oxygen    Hyperlipidemia  - Home statin continued during hospitalization and at discharge    Hypothyroidism  - Home levothyroxine continued during hospitalization and at discharge    Type 2 DM [A1c 7.8%]  - Patient received sliding scale insulin while inpatient, discharged to continue home metformin      Operative Procedures Performed Lumbar Puncture 8/9/2021 Large Volume Paracentesis 8/12/2021 Large Volume Paracentesis 8/12/2021   Consults: Oncology, Palliative Care, Surgical Oncology, Critical Care, Psychiatry    Physical Exam at Discharge Discharge Condition: poor Heart Rate: 101 Resp: 16 BP: 90/60 Temp: 36.3 °C (97.3 °F) SpO2: 90 %  Weight: 108 kg (238 lb 1.6 oz)   Gen: Asleep, in bed, wakes easily, in NAD  CV: RRR, normal S1 and S2, no murmurs. Trace lower extremity edema to the level of the mid shin  Respiratory: CTAB, no crackles or wheezes, asleep on nasal canula  GI: Abdomen soft, nontender, non-distended GU: Foley catheter in place  Integumentary: Warm, dry.  Psych: Tired appearing this morning