Age: 55.0
Sex: F
Vaccine: COVID19
Symptoms: Immunoglobulin therapy, Interstitial lung disease, Lung opacity, Lymphadenopathy, Lymphocyte count normal
Clinical narrative: Hospitalized (1.6.22 - 1.12.22); COVID-19 positive (12.7.21); Fully vaccinated - moderna x2 D/c Summary: Discharge Summary PA-C (Physician Assistant-Certified) ? ? Oncology Cosign Needed   DISCHARGE SUMMARY   DATE OF ADMISSION:  01/06/2022 DATE OF DISCHARGE:  01/12/2022 CONSULTATIONS 1. Diabetes Management was consulted. 2. Infectious Disease was consulted. 3. Pulmonary was consulted.   PROCEDURES The patient underwent bronchoscopy on 01/07/2022.   HOSPITAL COURSE This is a 56-year-old female with history of thyroid cancer, status post thyroidectomy and radioactive iodine, diabetes mellitus, recurrent low-grade follicular lymphoma, who was on copanlisib.  Last cycle given in November.  In early December, she tested positive for COVID.  She struggled with symptoms at that time, presented to the emergency room on 01/06/2022 secondary to severe dyspnea on exertion, cough, and fatigue.    The patient was admitted to the hospital.  She was given supportive care.  ID and Pulmonary were consulted.  She had been on a course of Augmentin.  We completed a 10-day course of it.  She was started on Decadron daily with a taper.  She was also given remdesivir for 5 doses, the last day being on the 12th.  She continued to improve.  Her vitals were stable.  She was on room air.  Ambulatory pulse ox was negative.  She was ultimately discharged home on the 12th.    While she was here, Diabetes did follow the patient and did adjust her insulin according to her blood sugars.   DISCHARGE INSTRUCTIONS As follows:  She is to follow up with our office in 1 week.  Our office will contact her.   DISCHARGE MEDICATIONS ARE Acyclovir 400 mg daily; amlodipine 5 mg daily; Lipitor 10 mg daily; dexamethasone 2 mg on Thursday, Friday and Saturday and then stop; multivitamin daily; albuterol as needed; Tessalon Perles 100 mg every 4 hours as needed; citalopram total of 30 mg daily; levothyroxine 125 mcg daily.  I messaged the Diabetes Service for recommendations on insulin at discharge.    H&P: CHIEF COMPLAINT: COVID-19 in immunocompromised patient (HCC)     Assessment/Plan     ASSESSMENT / PLAN: Covid 19 Pneumonitis              - Ongoing symptoms, dx was on 12/07              - Troponin and BNP WNL 12/27, repeat x 1 now              - CTA neg for PE 12/27              - Respiratory Isolation              - ID consult for Compassionate use of Regeneron - Continue Decadron daily, 6mg x 3 days (completes 10 days), then 4 mg daily x 3, then 2mg daily x 3. - Augmentin started 12/31, continue through 01/09 to complete 10 days  - PRN albuterol inhaler, IS, cough suppressant,  - tele, Con't pulse ox - May need Cards consult if persistent tachy and/or pulm input if ongoing DOE for long haul managment   Recurrent Low Grade Follicular Lymphoma              - Dx 10/2012 sp R-CHOP x 6 cycles              - Sp Bendamustine and Rituxan x 6 cycles              -Sp IT prophy MTX x 4 cycles                   - Recurrence 06/2018, maintenance Rituxan until 04/2020              - 08/2020 started Revlimid and Gazyva                           -Serial CT's through 01/2021 mixed response, CT 03/2021 clear progression of disease              - 04/2021 started Copanlisib, C8 given 11/12/2021. Then put on hold for Covid 19              - Post Covid recovery possible Umbrasilib, vs Imbruvica and Venclexta, and CAR-T.               - POC per Dr.   Hx Thyroid Cancer              Sp thyroidectomy and radioactive iodine 2002              Synthroid per home regimen   DMII              Previously on Lantus 25 units and metformin at home due to chemo, but no longer.              BG was 288 today at facility              Lantus 25 units, add moderate dose ISS in setting of steroids              A1c is pending   HTN              Stable, no complaints              Home amlodipine   Hx Chronic Upper resp infections   Prophy              Lovenox PPI Subjective    SUBJECTIVE: Pt is a 56 yo female with a past hx of thyroid cancer s/p thyroidectomy and radioactive iodine 2002, as well as IDDM II on Lantus and metformin, and recurrent low grade follicular lymphoma, currently on Copanlisib, cycle 8 given 11/12/21 and held thereafter following Covid positive test 12/07. Pt has been struggling with ongoing fatigue, poor appetite, tachycardia, and DOE. She has not been hypoxic at rest. She presented to ER after 3 weeks of symptoms 12/27 and CTA ruled out a PE, CT thorax showed ongoing interstitial pneumonitis related to Covid infection. She responded to a dose of steroids at that time and some IVFs, troponin and BNP were WNL. Serum studies show no leukocytosis or neutropenia this AM at facility Hgb is 15.1. BMP also unremarkable. . Of note, her CT C/A/P from 12/27 also showed progression of lymphoma disease with increasing adenopathy of mesentery, retroperitoneal and neck and left supraclavicular regions.  She also has known hypogammaglobulinemia, last measured at 296 11/30/21 and treated with GammaGard 12/23/21.   She continues to have ongoing symptoms and presents from facility for admission for evaluation and treatment of SOB with severe DOE, cough and fatigue   History was provided by the patient. Review of Systems  Constitutional: Positive for appetite change (decreased) and fatigue. Negative for fever and specified pain.  HENT:   Negative for congestion, mouth sores, sore throat and trouble swallowing.   Eyes: Negative for eye problems.  Respiratory: Positive for chest tightness, cough and shortness of breath.   Cardiovascular: Negative for chest pain, palpitations and edema.       Racing heart  Gastrointestinal: Negative for abdominal distention, abdominal pain, nausea and vomiting.  Genitourinary: Negative for difficulty urinating, dyspareunia, dysuria and frequency.   Musculoskeletal: Negative for back pain, flank pain, neck pain, neck stiffness and extremity weakness.  Skin: Negative for rash and wound.  Neurological: Negative for dizziness, headaches, light-headedness, speech difficulty and extremity weakness.  Psychiatric/Behavioral: Negative for confusion, decreased concentration and depression. The patient is nervous/anxious.    Primary Hematologist/Oncologist:   OBJECTIVE: No vitals were available at the time this note was created   There is no height or weight on file to calculate BSA.  Physical Exam Constitutional:      Appearance: She is ill-appearing.  HENT:     Head: Normocephalic and atraumatic.     Nose: No congestion.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate.     Heart sounds: No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.     Comments: Diminished bibasilar  Abdominal:     General: Abdomen is flat. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Thought Content: Thought content normal.  Infectious Disease Progress Note - 1/11/22 INFECTIOUS DISEASE PROGRESS NOTE    ID follow up for: COVID-19   ASSESSMENT: 1. Covid 19.  Previously had 2 doses of moderna in Jan/Feb 2021.  Became symptomatic approximately 12/3.  Tested positive 12/7.  Evaluated by research team on 12/13 and not given monoclonals due to scarce resources.  Started dexamethasone 12/30.  Has residual pulm opacities and dyspnea with exertion.  No fevers.  Still testing + by PCR from NP swab and BAL on 1/7.  Cycle threshold on NP swab was 20.  Remdesivir started 1/8.  S/p BAL 1/7 with no identification of secondary bacterial or fungal pneumonia so far.  Antibodies positive for anti-spike protein therefore no role for monoclonal antibodies. 2. Follicular lymphoma, recurrent, low grade.  Dx 2012.  S/p R-CHOP then bendamustine and rituxan, IT MTX.  Had recurrence 2018 and placed on maintenance rituxan until 04/2020.  Started revlimid and gazyva 08/2020 with progression.  Started Copanlisib 04/2021, now on hold with covid. 3. Poorly controlled diabetes due to hyperglycemia with A1c 9.7. 4. Chronic sinusitis. 5. Hypogammaglobulinemia s/p IVIG 12/23.     PLAN: o Complete 5 days of remdesivir.  Today day 5/5. o Continue steroids with wean. o Await serum beta-D-glucan and aspergillus studies from BAL. o Remain off antibiotics as no evidence of secondary bacterial pneumonia and patient currently on room air. SUBJECTIVE: Interval events:  Seen resting comfortably in bed.  Reports ongoing improvement in respiratory effort.  Denies sputum production.  Review of systems: remaining ROS negative except as noted above OBJECTIVE:   Vitals: BP 117/66  | Pulse 67  | Temp 36.9 °C (Oral)  | Resp 16  | Ht 1.702 m  | Wt 68.5 kg  | LMP  (LMP Unknown)  | SpO2 98%  | BMI 23.65 kg/m²     Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is not diaphoretic.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     General: No scleral icterus.       Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Trachea: No tracheal deviation.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No stridor. No wheezing or rales.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No tenderness. Normal range of motion.     Cervical back: Normal range of motion and neck supple.  Skin:    General: Skin is warm and dry.     Findings: No erythema or rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood and affect normal.        Cognition and Memory: Memory normal.        Judgment: Judgment normal.