Historical past of Current Sickness 09/30/2022
Patient is very nice 48 years old male with historical past of basal cell carcinoma of the lungs, on chemotherapy, presenting with generalized weak point, left temporal and brow strain and ache in with nausea vomiting on and off for Three weeks. He has a recognized proper decrease lobe mass seen in August of 2022, he now additionally has lymph nodes in the suitable axilla that are painful and bleeding. CT of the mind present a possible dural based mostly MET(metastasis) within the left parietal lobe with out midline shift with some surrounding vasogenic edema. He has a recognized proper decrease lobe mass that was found in August of 2022, and he now has painful and bleeding lymph nodes in the suitable axilla. A CT scan of the mind reveals a possible dural-based MET (metastasis) within the left parietal lobe with some surrounding vasogenic edema.
Evaluate of Programs
Constitutional: No fever/chills, no weight reduction/achieve
Eyes: No double imaginative and prescient, no visible adjustments
ENT: No listening to loss/tinnitus, no nasal congestion
Cardiovascular: No chest ache, no palpitations
Respiratory: No shortness of breath, no cough
Gastrointestinal: No nausea/vomiting, no diarrhea
Genitourinary: No urinary incontinence, no urinary issue
Musculoskeletal: No important joint ache, no muscle cramps
Pores and skin: No rashes, no abrasions
Neurological: No weak point, no numbness
Psychiatric: No despair, no nervousness, Cooperative.
Endocrine: No warmth or chilly intolerance, no change in urge for food
Hematologic/Lymphatic: No straightforward bruising, no anemia
Allergic/Immunologic: No allergic response to meals, no swollen lymph nodes
Bodily Examination On arrival on 09/30/2022
GENERAL: No acute misery. Speech fluent.
CHEST: Respiration comfortably on room air.
CARDIOVASCULAR: Common charge
SKIN: Intact.
EXTREMITIES: Effectively perfused
PSYCH: Applicable
NEURO:
CN:
Peripheral fields intact
Pupils equal, spherical, reactive to mild
Additional-ocular actions intact
V1-V3 intact
Face symmetric
Listening to grossly intact
Palatal elevation symmetric
Shoulder shrug intact
Tongue midline
MOTOR:
5/5 Bilateral:
Grip
Bicep
Tricep
Dorsiflexion
Plantarflexion
SENSATION: Intact to mild contact
REFLEXES:
No hoffman
Patellar reflexes 2+
COORDINATION:
Finger to nostril intact
Assessment/Plan
Admit for left parietal MET
CT C/A/P to r/o METS
MRI Brainlab Plus/MRV
Decadron 4q6/Famotidine for Edema
Keppra for Sz ppx
Acetaminophen/Hydrocodone prn ache
NPO besides MEDS/ICU admit
SCDs for DVT ppx
. Mind metastasis C79.31
Ordered:MRV Head wo Distinction
Present prognosis
-Mind metastasis
-Metastatic basal cell carcinoma
-Pneumonia
– axillary mass
-cancer associated ache
Cerebral mind hemorrhage
Drawback Record/Previous Medical Historical past
Ongoing
Acute hypoxemic respiratory failure
Acute renal failure
In danger for falls
Axillary mass
BCC (basal cell carcinoma), again
Most cancers associated ache
Most cancers-related ache
Diarrhea as a consequence of drug
Diarrhea with dehydration
Encounter for antineoplastic immunotherapy
Encounter for immunotherapy
Hyponatremia
Joint ache
Leukocytosis
Metastasis to lung
Metastatic basal cell carcinoma
Weight problems
Ache
Pericardial effusion
Respiratory signs
Systemic inflammatory response syndrome
Tachypnea
Wheezing on expiration
Historic
2019 novel coronavirus
Anxiousness
Clostridium difficile
Clostridium difficile
Cough
Lung most cancers
Process/Surgical Historical past
•EXCISION OF ILEUM, ENDO, DIAGN (04/07/2022)
•EXCISION OF LARGE INTESTINE, ENDO, DIAGN (04/07/2022)
•AMPUTATION TOE INTERPHALANGEAL JOINT (06/25/2020)
•INTRODUCE OTH ANTINEOPLASTIC IN PERIPH VEIN, PERC (09/08/2019)
•EXTRACTION OF RIGHT AXILLARY LYMPHATIC, PERC APPROACH, DIAGN (08/23/2019)
Drugs
Inpatient
acetaminophen, 650 mg= 2 tab, PO, q4h, PRN
Albuterol- Ipratropium 3ml soln, nebulizer q6h for cough
Hydromorphone, 4mg 1 tab, PO , q8h prn, for ache
Trazodone 50mg 1 tab PO, nightly for sleep
Tamsulosin zero.8mg 2 caps, po nightly BPH
Dextromethorphan , 10mg syrup , q6h for cough
docusate-senna 50 mg-Eight.6 mg oral pill, 2 tab, PO, 2x/day
Heparin 5000U, 1ml, inj SC q8hr for DVT prophylaxis
labetalol, 10 mg= 2 mL, IV Push, q30min, PRN
levETIRAcetam, 500 mg= 1 tab, PO, q12h for seizure
Melatonin 6mg 2tab po nightly
Pentoprazole 40mg 1tab po every day for Gerd
amLODIPine, 5 mg= 1 tab, PO, Every day
Allergy symptoms
morphine (hallucinations)
Social Historical past
Smoking Standing
By no means smoker
Alcohol
Use: Denies.
Substance Use
Use: Denies.
Tobacco/Nicotine
Use: Denies.
Household Historical past
Father: Diabetes mellitus sort 1
Mom: Diabetes mellitus sort 1
Second copy
Progress be aware the place you will get extra info
Chief Grievance
mind mass
Historical past of Current Sickness
48M PMH oculocutaneous albinism and metastatic basal cell carcinoma to the lungs and proper axilla on chemo p/w weak point, L temporal/brow strain/ache together with nausea x2-Three weeks. CTH demonstrates L parietal dural met with surrounding vasogenic edema. He was admitted to the Neuro ICU for additional administration and his hospital course is as follows:
9/29: CTH accomplished – heterogeneous harmful gentle tissue lesion centered in L parietal bone with intracranial/superficial extension (probably metastasis)
9/30: Decadron given. Keppra began. CT CAP accomplished – elevated pulm nodules measurement, R axilla lymphadenopathy. Palliative consulted. Mentioned CTH discovering with affected person’s outpatient Oncology, who states there are not any medical tx obtainable for the mind met and concur with surgical intervention the place a craniotomy was finished. LVNX began
10/1: Echo EF 55-60%
10/2: EGK obtained, MRI MRV accomplished
10/Three: BUE Dopplers damaging. Drugs seek the advice of for surgical clearance. Surg Onc seek the advice of for proper axilla mass
10/Four: Deemed Low Threat for OR a/p medication Cx. Surg Onc rec Rad Onc Cx as not surgical candidate for proper axilla mass. Rad Onc Cx positioned.
10/6: Consent obtained for OR.
10/7: OR left craniectomy for tumor resection, reconstructive cranioplasty
10/Eight: MRI: publish surgical adjustments, HMV d/c
10/9: PT: outpatient. Foley d/c. void trial Transferred to 2F for ground care
10/11: New headache. CTH accomplished – L parietal extracranial/intracranial hematoma with R-ward shift. CT PE (-). Trop (-). ECG (-). RRT known as. OR for L crani for EDH evacuation. Intraop TEG inhibited, obtained 1u plts.
10/12: TEG accomplished – AA 92.2, ADP 47.6. CTH post-op adjustments. HSQ began. PO weight loss program began.
10/13: CTH secure, HMV drain dc’d, transferred all the way down to Neuro IMC. CXR (-) for acute abnl. Covid (-). PT suggest outpt PT
10/14: CTH accomplished – secure. Decadron x24h for headache. Closing pathology: basal cell carcinoma
10/16: Hgb 6.zero, sp 2U PRBC, Lactate 1.1, began on empiric Vanc, Zosyn. Transferred to medication group as main.
Oncologic historical past and How the Patient’s illness course of all began.
He was initially identified with basal cell carcinoma in the suitable forearm in 2011. This was handled with liquid nitrogen however he began creating extra lesions by his physique together with a again lesion in 2013, which was handled with surgical procedure. Over the course of the following 12 months or two he developed extra pores and skin cancers all around the physique together with his arms and forearms, his shoulders, proper face and in addition different a part of the torso. It seems that all these lesions have been eliminated by surgical procedure however some might have been handled with cryotherapy. In 2018, he had chest x-ray for brand new cough and he was discovered to have at the least two lung lesions. He had a biopsy finished on the time (7/2018) which confirmed metastatic basal cell carcinoma. He was began on Erivedge (Vismodegib) and he didn’t tolerate that drug. He was oxygen dependent and had hemoptysis in Aug 2019 and had improved respiratory standing on excessive dose steroid with taper, obtained first dose of Keytruda (flat dose of 200mg IV q3weeks) on 9/9/2019 within the hospital and second dose onwards he was getting it outpatient on the infusion middle. Progressed (solely within the chest) in late fall of 2021 and on Nivolumab 400 mg/Ipilimumab 1 mg/kg salvage remedy q4w.
As of April 2022 and after Three cycles of nivolumab/ipilimumab remedy (with response), he developed checkpoint inhibitor mediated autoimmune inflammatory bowel illness. He was admitted to the hospital with intense gastrointestinal administration and on steroid within the type of methylprednisolone equal of 100 mg of prednisone (1mg/kg), he improved together with Imodium and Reglan.
Additionally through the hospitalization in April 2022, CT stomach pelvis confirmed a number of spiculated pulmonary nodules and masslike areas of consolidation that have been unchanged from current. Patient underwent colonoscopy on Four/7/2022 that confirmed ileitis in addition to colitis. Stool cultures have been damaging. He was positioned on IV Solu-Medrol and was discharged on prednisone with tolerance.
He has been evaluated by rad/onc throughout this admission and really helpful palliative XRT to proper axilla which may be managed at a facility nearer to his dwelling in Maryland.
On analysis, he is resting in mattress, accompanied by his mom within the room. He states that he has productive cough with yellow sputum that began Three days in the past. Denies hemoptysis, SOB at relaxation, chest ache, palpitations, nausea/ vomiting, abd ache, diarrhea/ constipation.
Bodily Examination
Vitals & Measurements
T: 37 °C (Oral) TMIN: 36.6 °C (Oral) TMAX: 37.5 °C (Oral) HR: 97(Monitored) RR: 28 BP: 125/60 SpO2: 96% WT: 91.5 kg
Oxygen Supply System: Nasal cannula (10/16/22 04:00:00)
Oxygen Circulation Charge: 2 L/min (10/16/22 04:00:00)
Progress be aware for 10/16/2022
Common: Effectively developed, properly nourished. Denies ache. Alert and oriented, no acute misery.
Eye: Bilateral pupils seem pink, spherical, equal and reactive to mild bilaterally. Extraocular motions intact. No sinus tenderness. Sclera are non-icteric and the conjunctiva are pink bilaterally
HENT: Surgical staples famous on head. Regular listening to, moist oral mucosa. Oropharynx clear and with out edema, injection nor exudate.
Neck: Supple, non-tender, with full vary of movement, no carotid bruits, no JVD.
Lungs: Good air entry bilaterally. Coarse breath sounds with L basilar crackles.
Coronary heart or Cardiovascular: Regular charge, common rhythm, no murmur, gallop or rub. There is no peripheral edema. Distal pulses robust and equal in all limbs.
Stomach: Tender, supple, non-distended. No tenderness to palpation. Bowel sounds are current and regular. No lots or organomegaly famous.
Musculoskeletal: No gross deformity of extremities. All extremities transfer properly with full vary of movement and power, no tenderness or swelling.
Pores and skin: Pores and skin is heat and dry. Albinism.
Neurologic: Awake, alert, and oriented to individual, place and time. Cranial Nerves II-XII are grossly intact. Sensation to mild contact intact. No focal motor deficits. Energy and sensation are intact with none focal deficit.
Psychiatric: Cooperative, acceptable temper, have an effect on, and thought.
Assessment/Plan
48 yoM with PMH oculocutaneous albinism, metastatic basal cell carcinoma to lungs, R axilla and bones on Chemo, admitted on 9/30 with newly identified presumed left mind mets s/p L craniectomy transferred to medication main group for administration of productive cough regarding for HAP.
#SIRS
#Productive Cough
Patient developed productive cough with yellowish thick sputum Three days in the past. He has been afebrile, however tachypneic, tachycardiac. Leukocytosis probably reactive publish surgical procedure is downtrending. CXR 10/15 no new infiltrative course of. UA wnl.
Etiology: regarding for HAP vs metastatic lung illness
– Proceed Zosyn and Vanc (dosing by pharmacy)
– Proceed Tessalon Perles, Robitussin 400mg This fall PRN
– Proceed Nebulizer remedy 4x/day PRN
– MRSA swab
– Urine for strep pneumo/ legionella
– Examine procalcitonin
– F/u sputum tradition
– F/u blood tradition
#L Mind Met 2/2 basal cell lung CA s/p Left craniotomy (10/7) s/p emergent hematoma evacuation 10/11
– Proceed care in Neuro ICU
– Q2h neuro checks, okay sleep protocol and q2h important indicators
– Proceed Keppra 500mg BID for seizure ppx
– SBP aim 100-160
– Na aim normonatremia
– Repeat CTH Monday, ordered
– Closing path reveals metastatic basal cell carcinoma
– Palliative care onboard for GOC and symptom administration
Ache administration:
– Quick course Decadron accomplished 10/16
– proceed Fioricet PO q4h PRN
– proceed oxycodone 5mg PO q4h PRN ache 1-Four
– proceed oxycodone 10 mg PO q4h PRN ache 5-10
#R Axillary Mass
-Onc surgical procedure consulted, not recommending surgical procedure at the moment
-Rad Onc on board, really helpful XRT to the suitable axilla publish resection of intracranial mass
#Normocytic Anemia
Seemingly etiology of acute blood loss from current surgical procedures along with anemia of continual illness/ metastatic malignancy
Hb on 10/16: 6, transfused 2u pRBC
– F/u publish transfusion hb
– F/u ferritin, TIBC
– Transfuse aim Hb >7
Code: Code Standing Full Code – Ordered
Food regimen: Common Food regimen – Ordered
— 10/12/22 Eight:51:00 EDT
DVT PPx: Heparin SC
GI PPx: Protonix
Tele: Sure
Restraints: None
Isolation/Precaution: None
L/T/D: Traces
PIV Forearm Left 20 G 2.5 cm – Peripheral IV Exercise: Assessed (10/16/22 07:00:00)
PIV Forearm Proper 22 G 2.5 cm – Peripheral IV Exercise: Assessed (10/16/22 12:00:00)
Some Progress be aware in regards to the affected person 0n 10/16/22. Please pay attention to the brand new adjustments.
48M PMH HNT, recognized lung most cancers on 2 L nasal cannula (per chart, nonetheless per sister had not been on oxygen for the previous couple months) w/mind mets now s/p hemicrani and repeat OR for hematoma 5 days in the past, now ~2 days with chills, sweats, temperatures 99.9 °F, cough with yellowish thick sputum, fatigue, poor sleep, in addition to hemoglobin dropped to six now getting 2 items PRBCs transfused by neurosurgery. Per affected person and sister at bedside, the signs didn’t begin when the affected person was admitted or instantly after both operation, however Three days after her final operation. Blood tradition x1 despatched, decrease extremity Dopplers bilateral and FOBT ordered by neurosurgery group.
BP:(93 – 136)/(53 – 72)HR:(78 – 109)RR:(18 – 30)T:(36.60 – 37.50)
Common: Effectively developed, overweight. Denies ache. NAD
Eye: PERRL. No sinus tenderness, Regular showing conjunctiva.
HENT: moist oral mucosa. Oropharynx clear and with out edema, injection nor exudate. Thyroid not enlarged, massive cranial scar with many stitches
Neck: non-tender, no LAD
Lungs: On 2 L nasal cannula, crackles at left base, coarse breath sounds, coughing
Coronary heart or Cardiovascular: RRR, no M/R/G. No JVD. Distal pulses robust and equal in all limbs.
Stomach: Tender, non-distended. No tenderness to palpation. +BS. No lots or organomegaly famous.
MSK: no leg swelling
Pores and skin: Pores and skin is heat, dry. No rashes or lesions. Albinism
Neurologic: ANOx4
Psychiatric: Cooperative, acceptable temper, have an effect on, and thought.
Neuro/Psych — No ache/sedation, ANOX4
Resp –2 L nasal cannula, elevated oxygen necessities, no massive adjustments in x-ray potential lobar pneumonia? On antibiotics follow-up cultures procalcitonin; nebulizer Tessalon Perles
Cardio –NAI
Infect –possible pneumonia on prime of recognized metastatic lung illness
Gastro –NAI
Genitourinary/Lytes — Dose drugs to GFR.
Heme/Onc –getting 2 items of PRBC, follow-up publish transfusion CBC
Endo — BG aim 140-180 mg/dl
Integumentary –hemicrania scar
Lab Outcomes
CBC 10/16/22 02:10 10/14/22 05:02 10/13/22 12:46
WBC 24.92H 31.13H 32.46H
Hgb 6.0LC 7.3L Eight.2L
Hct 18.7LC 22.2L 24.5L
Plt 325 318 327
BMP 10/16/22 02:10 10/14/22 05:02 10/13/22 03:53
Sodium 137 130L 133L
Potassium Four.2 Four.Four Four.zero
Chloride 103 95L 98
CO2 31 28 30
BUN 9 10 12
Creatinine zero.70 zero.63 zero.64
Glucose Random 108 133 114
COAG 10/11/22 20:21 10/07/22 03:52 09/30/22 00:44
PT 13.7 13.7 13.5
INR 1.zero 1.zero 1.zero
PTT 26.7 36.2
10/21/2022 (please these are essentially the most present labs)
WBC = Eight.24, Hgb = 9.7L, Hct = 31.1L, platelet = 333, RBC = Three.57L, RDW = 17.1H,
Sodium = 139, Potassium = Three.9, Chloride = 104, CO2 = 28L, BUN = 8L, Creatinine = zero.70, Glucose = 139, Complete protein = 6.Three, calcium = Eight.9, Globulin = 2.6, AST = 41H, ALT = 64H
Lactate (final Three in 48H)
Lactic Acid Lvl: 1.1 mmol/L (10/16/22 02:10:00)
Lactic Acid Lvl: 2.6 mmol/L Excessive (10/15/22 00:38:00)
Lactic Acid Lvl: 2.Eight mmol/L Excessive (10/14/22 21:29:00)
Some full Diagnostic Outcomes
ult Sort: CT Chest Stomach Pelvis wo IV Distinction
End result Date: September 30, 2022 03:42 EDT
* Closing Report *
Cause For Examination
Different (Specify)
HISTORY: Mind/CNS neoplasm, staging
FINDINGS:
Anterior proper shoulder pores and skin nodularity is partially visualized. Proper axillary nodule is 1.5 cm. Calcified mediastinal and hilar lymph nodes are unchanged. No pleural or pericardial effusion is seen. The guts is regular in measurement.
The dominant bilateral pulmonary lots are grossly secure in measurement although among the nodules have enlarged. For instance, nodule on the proper main fissure superiorly has enlarged from Three.9 to Four.6 cm. There is in depth new interstitial thickening and nodularity inside the center lobe. The left higher lobe and proper decrease lobe bronchi are occluded by lots.
The unenhanced liver, gallbladder, spleen, pancreas, kidneys and adrenal glands are unremarkable.
The unenhanced bowel is unremarkable. The urinary bladder is thick-walled and the prostate is enlarged at 6 cm transversely. Proper mesenteric lymph nodes are mildly enlarged.
No suspicious osseous lesions are identifie
End result Sort: MRI Mind wo w Distinction
End result Date: October 02, 2022 16:38 EDT
Cause For Examination
Different (Specify)
REPORT
EXAM: MRI Mind with and with out Distinction:
CLINICAL INDICATION: Lung most cancers
COMPARISON STUDY: CT dated September 29, 2022
FINDINGS:
A harmful lesion the left parietal calvarium is once more seen. There is intra and extracranial extension. The lesion extends to the superior sagittal sinus however doesn’t compromise its lumen. The intracranial extension measures at the least 70 mm x 14 mm in depth. There is no important edema of the underlying mind.
Ventricles are regular in measurement and place.
No Intra or extra-axial bleeding is famous. The orbits, sella, and craniocervical junction have a standard look. Regular sign void is seen in main arterial and dural venous constructions.
(10/14/2022 00:56 EDT CT Head wo Distinction)
EXAM: CT of the pinnacle with out distinction
REASON FOR EXAMINATION:, Cranioplasty
COMPARISON: October 13, 2022
TECHNIQUE:
Axial photographs have been obtained from the cranium base to the vertex with out intravenous distinction.
FINDINGS:
Patient is standing publish resection of a bony metastatic lesion within the left parietal area with subsequent cranioplasty. A small quantity of blood and surrounding edema is once more seen beneath the anterior facet of the cranioplasty. This measures roughly 10 mm.
Ventricles are regular in measurement and place. There is no shift of midline constructions.
IMPRESSION:
Steady research. [2]
[1] XR Chest 1 View Transportable; Ahn, MD, Julia Y. 10/15/2022 12:34 EDT
[2] CT Head wo Distinction; Monsein, MD, Lee Haskell 10/14/2022 00:56 EDT
(10/15/2022 12:34 EDT XR Chest 1 View Transportable)
Examination: Radiograph of the chest 1 view
Indication:Historical past of lung most cancers
Approach: Single frontal view of the chest
Comparability: 10/13/2022
Findings:Cardiac silhouette is mildly enlarged. Redemonstrated are nodular opacities in step with affected person’s recognized metastatic lung illness. Redemonstrated are bilateral perihilar lots. Left decrease lobe opacities current. No discernible pneumothorax. Osseous constructions are unchanged.
Impression:Steady examination. [1]
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