Note 6 Dec 2021 Patient is a 71 y.o. female. with emphysema, coronary artery disease s/p 3 stents '05, and metastatic bladder cancer admitted for shortness of breath and thrombocytopenia; found to have submassive PE. Rapid responded 12/6 for increased work of breathing, currently on comfort flow.   covid vaccines pfizer on 3/3/2021, 3/24/2021, and booster on 9/16/2021,  plt count 80,000  on 13 sep 2021 prior to booster,  and dropped to 16,000 by 10/21/2021.   1. Thrombocytopenia -since August, admitted at 14K. Currently 41K s/p daily transfusions -previously been attributed to ITP secondary to immunotherapy, however this has not responded to first-line treatments including corticosteroids and IVIG in the outpatient setting -10/29/21 Bone marrow biopsy: Mildly hypercellular bone marrow (50% cellular) with erythroid hyperplasia. No diagnostic immunophenotypic abnormalities are detected by flow cytometry. Cyto was pending. Iron stain demonstrates adequate storage iron.  -ADAMTS13 67%-normal -INR 1.1, fibrinogen 183 -B12 734 -haptoglobin 78, LDH 813, 1123 -negative HIT Ab X 2 -s/p Dex 40mg daily X 4; 1gm solumedrol daily 11/30-12/2 -negative drvvt, CL and beta 2 Ab -Started Promacta 50mg po daily 11/12; increased to 75mg po daily 11/25; increased to 100mg 12/1   2. Anemia -Hgb 8.3 -Prior occult GI bleed and was tranfused 1 unit in October 2021 but not scopre was performed; reports dark stools recently  -ferritin 200, TIBC 335, % sat 24, iron 81   3. PE, acute; RV thrombus -exertional CP and SOB X 2 weeks -D-dimer 27350 -CTA chest performed and showed Bilateral segmental pulmonary emboli with prominent right heart strain, bowing of the intraventricular septum, dilation of the right atrium.Prominent likely unstable thrombus within the right ventricle, consider ECHO interrogation of the right ventricle, Subpleural nodules within the left lower lung, which are stable to slightly increased in size since prior exam. Differential diagnoses include metastases (given history of bladder cancer) or primary lung malignancy. Infectious/inflammatory etiology is felt less likely. Tissue sample recommended if clinically indicated for further evaluation. -venous doppler of legs showed no DVT -Etiology recent IVIG vs DIC vs. Cancer vs covid vaccine -heparin drip with prn platelet transfusions -11/19 cardiac MRI: suspicious for intracardiac tumor. Starting radiation 12/1 or 12/2.   -repeat echo 12/6 pending    4. Metastatic bladder cancer - dx 2020 s/p cystectomy March 2021, chemo, radiation April 2021, hysterectomy -dose dense MVAC in Dec 2020-Feb 2021 -found to have metastatic disease in April 2021.  -Developed autoimmune hepatitis with keytruda June 2021 -developed thrombocytopenia with avelumab, last dose 9/28/21 -Onc following- can not get enfortumab inpatient, recommending hospice    Recommendations: -Increased SOB and hypoxia today, pending Echo. Also with epistaxis on exam- please repeat CBC this afternoon and continue platelet transfusion to keep >50K while on heparin.  -With MRI findings of likely cardiac thrombus, it is more likley that her persistent thrombocytopenia is 2/2 hemolysis from shearing across the tumor and/or DIC and not ITP. Do not plan to administer Rituxan. Patient wants to go home- discussed with oncology that we could aim for platelet transfusion 3X/week and discharge on Lovenox 1 mg/kg BID (ok with DOAC if that's her preference however).  -Holding promacta given ongoing transaminitis  -pending radiation to intracardiac tumor -Heparin drip with prn platelet transfusion to keep >50K while on heparin -daily CBC, CMP  unfortunately she died 8 Dec 2021