Discharge Provider: MD Primary Care Provider: DO Admission Date: 9/17/2022 Discharge Date: 9/25/2022   Clinical Narrative:   Patient was admitted with post chemotherapy nausea vomiting and diarrhea.  He was quite volume depleted and had a mild lactic acidosis which resolved promptly.  He did continue to improve as outlined below.  He will be discharged home today with Oncology follow-up on Tuesday.     Please see the following problem-list oriented Hospital Course below:   Lactic acidosis Assessment & Plan The patient presented emergency department with likely chemotherapy-induced nausea vomiting diarrhea with pancytopenia lactic acidosis.  Patient given 2 L bolus in the emergency department lactic acidosis improved in decreased to 1.8 patient still having watery diarrhea in the emergency department.  The patient will be admitted will be given IV hydration will be given a dose of hydrocortisone as he is on oral hydrocortisone outpatient his oral dosing will be increased to 20 mg a.m. 10 mg p.m..   Lactic acidosis was likely secondary to the extent of his volume depletion and hemodynamic alteration after his chemotherapy, watery diarrhea, nausea, vomiting.  Resolved promptly.   * Pancytopenia Assessment & Plan Likely due to his chemotherapy.     Improved. Responded to Neupogen.  Antibiotics later stopped.  Observing.  Subsequent leukocytosis secondary to Neupogen therapy.   Diarrhea Assessment & Plan Nausea vomiting diarrhea lactic acidosis likely due to chemotherapy does have pancytopenia will be empirically covering him with antibiotics continue hydration will check blood cultures will check stool studies   - complicated by nausea and vomiting.  Post chemotherapy.  Complicated by hypokalemia and hypomagnesemia.  Both were repleted.  Complicated by lactic acidosis.  Improved.  Required volume resuscitation.  Did well.    COVID-19 Assessment & Plan Patient is a pleasant 80-year-old male with history of metastatic colon cancer to the liver is undergoing chemotherapy patient has had nausea vomiting diarrhea was seen in the emergency department on the 12th hydrated and discharged home patient has had persistent symptoms increasing fatigue presented emergency department is COVID positive pancytopenic hypotensive which resolved with fluid lactic acidosis which resolved with fluid.  Patient admitted for further care   - largely a incidental finding.  No corresponding symptoms.  The patient did have increasing oxygen needs near discharge but this responded to ambulation, incentive spirometer, and observation.  Repeat chest x-rays stable.  Recent CT angiogram without evidence of pulmonary embolus.  Small bilateral pleural effusions are present but did not require intervention.  This is likely residual from his volume resuscitation.   Malignant neoplasm of sigmoid colon Assessment & Plan History of colon cancer with metastases to the liver undergoing chemotherapy last dosing was September 6th gets dosing every 2 weeks.  Patient with nausea vomiting diarrhea pancytopenia lactic acidosis.  The patient admitted for further care   Oncology follow-up planned for Tuesday. Discussed.  Excellent baseline functional status.   Adrenal insufficiency Assessment & Plan History of adrenal insufficiency.  Resuscitation on admission hydrocortisone dosing increased in the short-term.  Tolerated well.   Home on his prior dosing.   Abdominal aortic aneurysm (AAA) without rupture Assessment & Plan History of abdominal aortic aneurysm status post stent placement. Continue to follow with PCP/serial observation as needed. Secondary prevention with BP control and lipid management.   Atrial fibrillation  Assessment & Plan Paroxysmal atrial fibrillation on flecainide (restarted) -  continued on Toprol and aspirin   Stable at discharge. CHADS Vasc = 2.   He has, over time, elected to stay on simple antiplatelet therapy.   Hypoxia Assessment & Plan   Oxygen needs had increased the day prior to discharge.  He required a CT angiogram which the exclude pulmonary embolus.  He is noted have bilateral pleural effusions and mild bibasilar infiltrates/atelectasis.  He responded to mobilization, incentive spirometer, and cough and deep breathing.  Discharge chest x-ray remained stable.  No residual oxygen need on discharge.  No corresponding symptoms.  Atelectasis with shunting.   Pleural effusion, bilateral Assessment & Plan   Bilateral pleural effusions present.  Likely secondary to the extent of volume resuscitation required on admission.  Small.  Did well without intervention.  Atelectasis present.  Discharge chest x-ray stable.  Exam stable.