Age: 63.0
Sex: M
Vaccine: COVID19
Symptoms: Abnormal behaviour, Acute kidney injury, Acute respiratory failure, Ammonia normal, Anaemia
Clinical narrative: Clinical Summary   This is a pleasant 64 y.o. male patient with history of multiple myeloma on maintenance therapy, cirrhosis, rectal cancer, anemia, and depression. He was recently discharged 8/19 after admission for hypercalcemia and AKI 2/2 to multiple myeloma, metastatic lesions on his femur. Presented again on 8/28 w/ weakness, shortness of breath, and pain. Positive for COVID on 8/25. Treated with steroids, HAP antibiotics. Patient had stable yet altered mental status through this hospitalization with workup unrevealing for etiology, thought likely delirium. Multiple follow ups anticipated on discharge.      Problem List Acute respiratory failure Covid-19 Virus Infection Date of onset of symptoms: 8/22/22 Symptoms present on admission: shortness of breath, cough Date of covid positive test: 8/25/22 (home test), positive on admission 8/28/22 Imaging: CXR with multifocal b/l airspace opacities, worse on L>R Weaned from 2L NC to RA Medical therapy: Paxlovid 8/26-8/29, Remdesevir on 8/29-9/2 given increased O2 requirement from baseline Current oxygen requirements: Room air 9/1/22 Decadron for COVID 8/28 - 9/3; stopped short of full 10 day course given improving respiratory status, possible iatrogenic contribution to delirium Anticipated special isolation end date: 9/4/22; masking guidance at home advised   HAP Symptoms started 2 days following recent discharge Presented with shortness of breath, cough and increased oxygen requirement CXR 8/28 with worsening atypical multilobar pneumonia, L>R Urine antigens + MRSA probe negative 8/28, sputum culture not yet collected C/f superimposed bacterial HAP in setting of immunosuppression S/p azithromocin and rocpehin in ED Vanc 8/28-8/29; MRSA probe negative Cefepime 8/28-9/3 BCx not collected as initiated on abx prior to opportunity to collect Discharged to complete 2 further days of levaquin for HAP coverage   Encephalopathy, improving Persistent waxing-waning encephalopathy, improved with wife present, otherwise abnormal/bizarre behaviors Consistently oriented to self and location, inconsistently oriented to date and situation  Ammonia wnl Per wife, new this admission CT head unremarkable Neurology initially consulted, however after discussion wife elected to discharge home with anticipated Neurology follow up; day of discharge patient with some improvement Likely multifactorial with COVID, hypercalcemia, potential delirium component Pancytopenia Likely 2/2 to worsening MM, COVID, chemotherapy On 8/19 Plt 20 and Hgb 7.2 On admission Plt 31 (b/l 40-50s), Hgb 8.3 (b/l 9.0) RUQ U/S with findings consistent with cirrhosis, splenomegaly Held ASA and Lovenox in setting of anemia, thrombocytopenia Never required Plt transfusion for threshold <10 Heme consult   Hypercalcemia, stable Likely 2/2 to multiple myeloma Recently admitted and at time of DC 8/19 Ca 9.2 Presented with fatigue, pain, polyuria Calcium 14.7, ionized Ca 8.7 on admission Phos 4.0, mag 1.5, PTH 14.8 IVF, Calcitonin, lasix, pamidronate utilized prn Monitored for signs of hypercalcemia, consider repeat level if present Discharged with stability ~Ca 11s   AKI, improved Likely 2/2 hypercalcemia as above Creatinine 1.8 on admission (b/l 0.9) IVF prn BMP trended   Cirrhosis Diagnosed 2015 Child Class B, MELD score 16 RUQ U/S 8/29 with cirrhosis, splenomegaly, no focal lesions, no ascites Last EGD with small (< 5 mm) esophageal varices, portal hypertensive gastropathy, erosive gastropathy - 2 year f/u recommended FOBT+ 9/1, GI consult placed in setting of this and anemia GI consult, no procedural intervention undertaken   Multiple Myeloma  Prior regimen: weekly velcade & dexamethasone Last admission complicated by L hip pain, s/p IMN with Ortho on 8/15 with biopsy showing spread of disease to femur Also with hypercalcemia and AKI as above, pancytopenia as below Oncology consult   Acute T7 Vertebral Fracture CT chest 8/24 with fracture of T7, possibly acute. Re-demonstration of compression deformities T9-12 MRI C/T/L spine with no mets, acute T7 fracture, T10, T11 fractures No acute surgical intervention, neuro checks q4h Upright T-spine X-rays stable Neurosurgery consulted given concerns for progression of disease, outpatient follow up planned Chronic DVT of LLE Doppler U/S with partially occlusive chronic DVT of left femoral and popliteal vv. Pt. received 1 dose of 1 mg/kg Lovenox around 0100 on 8/29 Held pharmacologic anticoagulation given anemia and thrombocytopenia, chronicity of DVT Instructed to follow up with Heme/Onc provider for outpatient recommendations on anticoagulation   UTI Symptoms of frequency, dysuria that started 8/22 Uclx 8/23 E. Coli and Proteus vulgaris resistant to Ampicillin, Bactrim and Gentamycin HAP coverage with concurrent coverage as well   Elevated Troponin Trop 33 on admission, trend to 30 Likely 2/2 to demand ischemia EKG with incomplete RBBB, similar to prior 8/11 Monitored for ischemic signs and symptoms   Peripheral edema Similar to exam on prior admission Echo 8/16/22: EF 66%, mild TVR With hypoalbuminemia in setting of cirrhosis as above BNP 2,561, unknown baseline Per wife's report, chronic following prior chemotherapy for rectal cancer BLE U/S with chronic DVT to LLE as above Continued compression stockings   Hypokalemia, resolved K 3.3 on 8/30 Addressed as warranted   Hx of rectal cancer Hx of rectal cancer with lung and liver mets 2013 Pathologic stage from 7/19/2013: Stage IVA (yT3(m), N0, M1a)  S/p FOLFOX and multiple resections S/p chemotherapy, resection of all known hepatic metastases and resection of the primary CT A/P in 7/2022 without obvous mets CEA from prior admission, WNL 1.14