Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Urine analysis normal, Vertebroplasty, Vitamin B12 normal, White blood cell count increased
Clinical narrative: Telephone Encounter - RN - 09/27/2021 2:38 PM  Formatting of this note might be different from the original. Spoke with daughter, pt feeling more exhausted and getting sob with activity since las OV. Feels like she can not function and is very pale per daughter. These s/s have gotten worse since last OV , not new. PO running 93-94% today , has not smoked for 2 months no respiratory s/s at all, her chronic smokers cough has resolved. Has been taking iron supplement as instructed at last OV with no improvement in s/s. Pt daughter does not want to take to ED unless emergent as they simply tell her she is anemic, give IV fluids and send her home to f/u with PCP. Pt scheduled appt tomorrow in office    Electronically signed by RN at 09/27/2021 2:42 PM    Back to top of Miscellaneous Notes  Telephone Encounter - MA - 09/27/2021 1:12 PM  Formatting of this note might be different from the original. Patient's daughter states that the patient has been seen several times in recent months for ongoing symptoms and they would like to know if something else is recommended. She states that the patient had back surgery and feels worse now then she did prior to the surgery. She states that the patient complains of being exhausted and SOB. She states that the last time the patient was in the office she had swollen ankles that has gotten smaller, but not by a lot. She states that the patient complains that her "legs feel like rubber." She states that they bought a home pulse ox and today the patient's reading is 91 but it has been running in the 80s. She states that the patient's pulse reading has been "high." Please advise.   Electronically signed by MA at 09/27/2021 1:15 PM    Back to top of Miscellaneous Notes  Admission Current 9/28/2021 - present (17 days) Hospital   Chronic obstructive pulmonary disease, unspecified COPD type Depression Other hyperlipidemia Severe sepsis Lesion of adrenal gland Compression fracture of T5 vertebra  Pathological fracture of vertebra due to neoplastic disease, initial encounter   Iron deficiency anemia   Elevated alkaline phosphatase level   History of alcohol abuse   Urinary retention  Hilar lymphadenopathy   Adenocarcinoma of lung, stage 4, right  Bone metastasis  Adrenal nodule   S/P kyphoplasty   Acute respiratory insufficiency  Leukocytosis  Pleural effusion on right  COVID-19 virus infection  COPD exacerbation (CMS/HCC) #Compression fracture of T5 vertebrae possibly secondary to neoplastic process vs injury vs osteopenia? -CT thoracic spine: At T5, there is a vertebroplasty with vertebral plana type appearance of the vertebral body with prevertebral swelling and soft tissue density as well as lucency through the bilateral pedicles and posterior elements, consistent with neoplasm. Presumed pathologic fracture. There appears to be some fragment of calcium or bone in the spinal column at the T5 level. There is loss of the fat planes around the central canal and foramen at this level as well as just above and below the compressed segment. Presumed cord compression although this is not certain and MRI would be helpful better evaluate this region.  -MRI thoracic spine: Rredemonstration of a severe pathologic compression fracture of the T5 vertebral body, likely secondary to neoplastic process. As stated, there is soft tissue extending into the spinal canal from the posterior aspect of the T5 vertebral body and also from the pedicles and posterior elements of T5. As a result, there is severe cord compression at the T5 level.There is also evidence of anterior subluxation of T4 and T5 secondary to tumor infiltration of the left and right superior articulating facets of T5. Therefore I believe there is evidence of instability of the thoracic spine at the T5 4-T5 level. There is 4 mm of anterior subluxation of T4 and T5 and some focal kyphosis of the thoracic spine at the T5 level.Bulky right hilar soft tissue mass or lymphadenopathy is partially seen on the sagittal images. This is probably due to neoplastic process. Plan: -Neurosurgery consulted: They are planning to complete a T2-T8/9 decompression and instrumented fusion on 9/30 or 9/31.  They will be ordering a CT of the T-spine for preoperative planning -We will continue to monitor neurological status closely -Bladder scans q2 shift  -Dilaudid for pain -Follow-up MRI of the brain  -Oncology consulted  -Radiation oncology consulted    #Severe sepsis [leukocytosis, tachycardia, tachypnea, hypoxia] possibly secondary to unknown source  DDx: less likely surgical site infection [site is intact, no erythema or fluctuance] Tachycardia could be 2/2 pain  -WBC 16.4, troponin <0.03, lactate 1.4  -WBC 12.1, lactate 0.6, procalcitonin <0.05 -Urinalysis negative, RSV panel negative Plan: -Started on cefepime and vancomycin (day 1) -Follow-up blood cultures and urine culture -Follow-up lactic, troponin, and procalcitonin -CBC and CMP daily -Continue to monitor on telemetry   #Lesion of the adrenal gland and hilar lymphadenopathy -CTA PE: Bulky right hilar and subcarinal lymphadenopathy. Left adrenal lesion measures 2 cm. The thoracic lymphadenopathy in the right hilum narrows the pulmonary arteries however no embolism is appreciated.  -CT abdomen/pelvis: 2 cm left adrenal lesion as seen on the chest CT is concerning for neoplasm   #Elevated alkaline phosphatase -ALK 133, GGT 16   #Iron deficiency anemia -Follows started her on iron supplementation  -Iron <10, transferrin 299.2, ferritin 29, folate 9.4, B12 348 -H/H 8.4/28.6 > 7.6/26.1 -No signs of bleeding on physical examination -Transfuse if less than 7   #COPD -Continue with Breo Ellipta daily and albuterol as needed -Continue with Singulair 10 mg daily   #Hyperlipidemia  -On atorvastatin 20 mg nightly at home   #Depression/anxiety  -On venlafaxine at home, dose needs to be verified   #History of alcohol abuse -Sober for the past 15 years  Patient is a 70 y.o. female with PMHx of COPD, iron deficiency anemia, hyperlipidemia, history of alcohol abuse, and depression/anxiety who presented to Hospital on 9/28/2021 as a direct transfer from Hospital.  Per the patient, she began to experience symptoms after she had spinal surgery done on 8/2/2021 for a fracture of her T6 vertebrae.  Since her surgery, she has felt extremely weak and fatigued, and has had minimal to no energy. She endorses progressively worsening pain near the original spinal surgical site.  She said that the pain normally radiates down and out, following along the edges of her ribs to her sternal area.  She described the pain as burning in nature and said it is very intense.  She said that the pain generally comes and goes and is usually worse with movement.  She stated that she has tried ice, heat, and was prescribed naproxen for the pain without any relief.  Her symptoms are associated with severe weakness in her legs, which she described this as having "spaghetti legs" and numbness of her groin area.  At this time, she denies any bladder or bowel incontinence.