Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Liver function test normal, Lymphadenopathy, Magnetic resonance imaging head abnormal, Necrosis, Neoplasm
Clinical narrative: An internal jugular venous thrombus. It also encased the distal cervical portion of the left ICA. There was a small left jugular digastric chain lymph node measuring up to 6 mm in short axis and an indeterminate low density level II node on the right measuring 8 mm in short axis. The patient underwent biopsy by Doctor on 1/22/2020. The biopsy revealed a squamous cell carcinoma poorly differentiated nonkeratinizing with necrosis and a basaloid appearance. Overall, P16 staining was negative and this was interpreted as a tumor not driven by HPV infection. The patient has a very distant history of bilateral parotidectomies. He also has issues with coronary artery disease. This has been controlled. He has a history of an internal jugular venous thrombus. It also encased the distal cervical portion of the left ICA. There was a small left jugular digastric chain lymph node measuring up to 6 mm in short axis and an indeterminate low density level II node on the right measuring 8 mm in short axis. The patient underwent biopsy by Doctor on 1/22/2020. The biopsy revealed a squamous cell carcinoma poorly differentiated nonkeratinizing with necrosis and a basaloid appearance. Overall, P16 staining was negative and this was interpreted as a tumor not driven by HPV infection. The patient has a very distant history of bilateral parotidectomies. He also has issues with coronary artery disease. This has been controlled. He has a history of pancreatitis and an element of chronic renal insufficiency.  PET/CT was done in our office on 1/29/2020 and this showed the infiltrative solid mass within the left carotid space extending from the left jugular fossa to the angle of the mandible. There was a separate hypermetabolic ovoid base of tongue mass, otherwise no areas of other disease were noted. He is s/p definitive treatment with carboplatin and radiation, ending on 3/31/20. MRI brain on 7/1/2021 shows persistent soft tissue thickening within the left carotid space and jugular fossa, with a new left cerebellar mass contiguous with the soft tissue thickening, likely representing extension of disease. There is internal hemorrhage within this mass and mild midline shift but no hydrocephalus. He was seen by Dr. with Rad/oncology and completed palliative radiation 8/2021. He has a PEG tube and receives tube feeds. He was admitted last 8/20/21 for peg tube infection and PNA. His peg tube was exchanged by Dr. on 8/24. Patient presented to clinic 2/15. He was diagnosed with LLL PNA via CTA on 1/28 and COVID on 1/31. He has completed 2 rounds of augmentin and continues to have dyspnea and a productive cough. He was mildly hypoxic in clinic with o2 sats 88%. He reported being as low as 83% at home. He was also tachy with a low grade fever of 99.5. He saw an APP and was ultimately sent to the ER for admission and treatment of his progressive PNA. On arrival to the ER his VSS and he had good o2 saturations on RA. He did request some o2 over his trache for comfort. EKG w/ sinus tach. Labs reveal HGB of 9.9, o/w CBC looked good. Lytes, kidney function, LFTs good. Procal elevated at 0.31. ProBNP normal. BLCX pending. CXR revealed LLL PNA. CTA pending.  He continues to test positive for COVID and is being admitted to the COVID unit. Discussed with hospitalist. Patient reportedly received monoclonal AB on 2/1. Hospitalists did not recommend additional treatment for the time being aside from broad spectrum ABX.  He was placed on vancomycin, cefepime, and doxy for atypical. He has a PEG tube. PATIENT REMAINS INPATIENT AT THIS TIME.