Posted: May 12th, 2022

Patient is very nice 48 years old male

History of Present Illness 09/30/2022

Patient is very nice 48 years old male with history of basal cell carcinoma of the lungs, on chemotherapy, presenting with generalized weakness, left temporal and forehead pressure and pain in with nausea vomiting on and off for 3 weeks. He has a known right lower lobe mass seen in August of 2022, he now also has lymph nodes in the right axilla which are painful and bleeding. CT of the brain show a likely dural based MET(metastasis) in the left parietal lobe without midline shift with some surrounding vasogenic edema. He has a known right lower lobe mass that was discovered in August of 2022, and he now has painful and bleeding lymph nodes in the right axilla. A CT scan of the brain reveals a likely dural-based MET (metastasis) in the left parietal lobe with some surrounding vasogenic edema.

Review of Systems

Constitutional: No fever/chills, no weight loss/gain
Eyes: No double vision, no visual changes
ENT: No hearing loss/tinnitus, no nasal congestion
Cardiovascular: No chest pain, no palpitations
Respiratory: No shortness of breath, no cough
Gastrointestinal: No nausea/vomiting, no diarrhea
Genitourinary: No urinary incontinence, no urinary difficulty
Musculoskeletal: No significant joint pain, no muscle cramps
Skin: No rashes, no abrasions
Neurological: No weakness, no numbness
Psychiatric: No depression, no anxiety, Cooperative.
Endocrine: No heat or cold intolerance, no change in appetite
Hematologic/Lymphatic: No easy bruising, no anemia
Allergic/Immunologic: No allergic response to food, no swollen lymph nodes

Physical Exam On arrival on 09/30/2022
GENERAL: No acute distress. Speech fluent.
CHEST: Breathing comfortably on room air.
CARDIOVASCULAR: Regular rate
SKIN: Intact.
EXTREMITIES: Well perfused
PSYCH: Appropriate
NEURO:
CN:
Peripheral fields intact
Pupils equal, round, reactive to light
Extra-ocular movements intact
V1-V3 intact
Face symmetric
Hearing grossly intact
Palatal elevation symmetric
Shoulder shrug intact
Tongue midline
MOTOR:
5/5 Bilateral:
Grip
Bicep
Tricep
Dorsiflexion
Plantarflexion
SENSATION: Intact to light touch
REFLEXES:
No hoffman
Patellar reflexes 2+
COORDINATION:
Finger to nose 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 pain
NPO except MEDS/ICU admit
SCDs for DVT ppx

. Brain metastasis C79.31
Ordered:MRV Head wo Contrast

Current diagnosis

-Brain metastasis
-Metastatic basal cell carcinoma
-Pneumonia
– axillary mass
-cancer related pain
Cerebral brain hemorrhage

Problem List/Past Medical History

Ongoing
Acute hypoxemic respiratory failure

Acute renal failure

At risk for falls

Axillary mass

BCC (basal cell carcinoma), back

Cancer related pain

Cancer-related pain

Diarrhea due to drug

Diarrhea with dehydration

Encounter for antineoplastic immunotherapy

Encounter for immunotherapy

Hyponatremia

Joint pain

Leukocytosis

Metastasis to lung

Metastatic basal cell carcinoma

Obesity

Pain

Pericardial effusion

Respiratory symptoms

Systemic inflammatory response syndrome

Tachypnea

Wheezing on expiration

Historical
2019 novel coronavirus

Anxiety

Clostridium difficile

Clostridium difficile

Cough

Lung cancer

Procedure/Surgical History
•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)

Medications

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 pain

Trazodone 50mg 1 tab PO, nightly for sleep

Tamsulosin 0.8mg 2 caps, po nightly BPH

Dextromethorphan , 10mg syrup , q6h for cough

docusate-senna 50 mg-8.6 mg oral tablet, 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 daily for Gerd

amLODIPine, 5 mg= 1 tab, PO, Daily

Allergies

morphine (hallucinations)

Social History

Smoking Status
Never smoker

Alcohol

Use: Denies.

Substance Use

Use: Denies.

Tobacco/Nicotine

Use: Denies.

Family History
Father: Diabetes mellitus type 1
Mother: Diabetes mellitus type 1

Second copy

Progress note where you can get more information

Chief Complaint

brain mass

History of Present Illness

48M PMH oculocutaneous albinism and metastatic basal cell carcinoma to the lungs and right axilla on chemo p/w weakness, L temporal/forehead pressure/pain along with nausea x2-3 weeks. CTH demonstrates L parietal dural met with surrounding vasogenic edema. He was admitted to the Neuro ICU for further management and his hospital course is as follows:
9/29: CTH completed – heterogeneous destructive soft tissue lesion centered in L parietal bone with intracranial/superficial extension (likely metastasis)
9/30: Decadron given. Keppra started. CT CAP completed – increased pulm nodules size, R axilla lymphadenopathy. Palliative consulted. Discussed CTH finding with patient’s outpatient Oncology, who states there are no medical tx available for the brain met and concur with surgical intervention where a craniotomy was done. LVNX started
10/1: Echo EF 55-60%
10/2: EGK obtained, MRI MRV completed
10/3: BUE Dopplers negative. Medicine consult for surgical clearance. Surg Onc consult for right axilla mass
10/4: Deemed Low Risk for OR a/p medicine Cx. Surg Onc rec Rad Onc Cx as not surgical candidate for right axilla mass. Rad Onc Cx placed.
10/6: Consent obtained for OR.
10/7: OR left craniectomy for tumor resection, reconstructive cranioplasty
10/8: MRI: post surgical changes, HMV d/c
10/9: PT: outpatient. Foley d/c. void trial Transferred to 2F for floor care
10/11: New headache. CTH completed – L parietal extracranial/intracranial hematoma with R-ward shift. CT PE (-). Trop (-). ECG (-). RRT called. OR for L crani for EDH evacuation. Intraop TEG inhibited, received 1u plts.
10/12: TEG completed – AA 92.2, ADP 47.6. CTH post-op changes. HSQ started. PO diet started.
10/13: CTH stable, HMV drain dc’d, transferred down to Neuro IMC. CXR (-) for acute abnl. Covid (-). PT recommend outpt PT
10/14: CTH completed – stable. Decadron x24h for headache. Final pathology: basal cell carcinoma
10/16: Hgb 6.0, sp 2U PRBC, Lactate 1.1, started on empiric Vanc, Zosyn. Transferred to medicine team as primary.

Oncologic history and How the Patient’s disease process all started.

He was initially diagnosed with basal cell carcinoma in the right forearm in 2011. This was treated with liquid nitrogen but he started developing more lesions through his body including a back lesion in 2013, which was treated with surgery. Over the course of the next year or two he developed more skin cancers all over the body including his arms and forearms, his shoulders, right face and also other part of the torso. It appears that all these lesions were removed by surgery but some may have been treated with cryotherapy. In 2018, he had chest x-ray for new cough and he was found to have at least two lung lesions. He had a biopsy done at the time (7/2018) which showed metastatic basal cell carcinoma. He was started on Erivedge (Vismodegib) and he did not tolerate that drug. He was oxygen dependent and had hemoptysis in Aug 2019 and had improved respiratory status on high dose steroid with taper, received first dose of Keytruda (flat dose of 200mg IV q3weeks) on 9/9/2019 in the hospital and second dose onwards he was getting it outpatient at the infusion center. Progressed (only in the chest) in late fall of 2021 and on Nivolumab 400 mg/Ipilimumab 1 mg/kg salvage treatment q4w.

As of April 2022 and after 3 cycles of nivolumab/ipilimumab treatment (with response), he developed checkpoint inhibitor mediated autoimmune inflammatory bowel disease. He was admitted to the hospital with intense gastrointestinal management and on steroid in the form of methylprednisolone equivalent of 100 mg of prednisone (1mg/kg), he improved along with Imodium and Reglan.

Also during the hospitalization in April 2022, CT abdomen pelvis showed multiple spiculated pulmonary nodules and masslike areas of consolidation that were unchanged from recent. Patient underwent colonoscopy on 4/7/2022 that showed ileitis as well as colitis. Stool cultures were negative. He was placed on IV Solu-Medrol and was discharged on prednisone with tolerance.

He has been evaluated by rad/onc during this admission and recommended palliative XRT to right axilla which can be managed at a facility closer to his home in Maryland.

On Assessment, he is resting in bed, accompanied by his mother in the room. He states that he has productive cough with yellow sputum that started 3 days ago. Denies hemoptysis, SOB at rest, chest pain, palpitations, nausea/ vomiting, abd pain, diarrhea/ constipation.

Physical Exam
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 Delivery Device: Nasal cannula (10/16/22 04:00:00)
Oxygen Flow Rate: 2 L/min (10/16/22 04:00:00)

Progress note for 10/16/2022

General: Well developed, well nourished. Denies pain. Alert and oriented, no acute distress.
Eye: Bilateral pupils appear red, round, equal and reactive to light bilaterally. Extraocular motions intact. No sinus tenderness. Sclera are non-icteric and the conjunctiva are pink bilaterally
HENT: Surgical staples noted on head. Normal hearing, moist oral mucosa. Oropharynx clear and without edema, injection nor exudate.
Neck: Supple, non-tender, with full range of motion, no carotid bruits, no JVD.
Lungs: Good air entry bilaterally. Coarse breath sounds with L basilar crackles.
Heart or Cardiovascular: Normal rate, regular rhythm, no murmur, gallop or rub. There is no peripheral edema. Distal pulses strong and equal in all limbs.
Abdomen: Soft, supple, non-distended. No tenderness to palpation. Bowel sounds are present and normal. No masses or organomegaly noted.
Musculoskeletal: No gross deformity of extremities. All extremities move well with full range of motion and strength, no tenderness or swelling.
Skin: Skin is warm and dry. Albinism.
Neurologic: Awake, alert, and oriented to person, place and time. Cranial Nerves II-XII are grossly intact. Sensation to light touch intact. No focal motor deficits. Strength and sensation are intact without any focal deficit.
Psychiatric: Cooperative, appropriate mood, affect, 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 diagnosed presumed left brain mets s/p L craniectomy transferred to medicine primary team for management of productive cough concerning for HAP.

#SIRS
#Productive Cough
Patient developed productive cough with yellowish thick sputum 3 days ago. He has been afebrile, but tachypneic, tachycardiac. Leukocytosis likely reactive post surgery is downtrending. CXR 10/15 no new infiltrative process. UA wnl.
Etiology: concerning for HAP vs metastatic lung disease
– Continue Zosyn and Vanc (dosing by pharmacy)
– Continue Tessalon Perles, Robitussin 400mg Q4 PRN
– Continue Nebulizer treatment 4x/day PRN
– MRSA swab
– Urine for strep pneumo/ legionella
– Check procalcitonin
– F/u sputum culture
– F/u blood culture

#L Brain Met 2/2 basal cell lung CA s/p Left craniotomy (10/7) s/p emergent hematoma evacuation 10/11
– Continue care in Neuro ICU
– Q2h neuro checks, ok sleep protocol and q2h vital signs
– Continue Keppra 500mg BID for seizure ppx
– SBP goal 100-160
– Na goal normonatremia
– Repeat CTH Monday, ordered
– Final path shows metastatic basal cell carcinoma
– Palliative care onboard for GOC and symptom management
Pain management:
– Short course Decadron completed 10/16
– continue Fioricet PO q4h PRN
– continue oxycodone 5mg PO q4h PRN pain 1-4
– continue oxycodone 10 mg PO q4h PRN pain 5-10

#R Axillary Mass
-Onc surgery consulted, not recommending surgery at this time
-Rad Onc on board, recommended XRT to the right axilla post resection of intracranial mass

#Normocytic Anemia
Likely etiology of acute blood loss from recent surgeries in addition to anemia of chronic disease/ metastatic malignancy
Hb on 10/16: 6, transfused 2u pRBC
– F/u post transfusion hb
– F/u ferritin, TIBC
– Transfuse goal Hb >7

Code: Code Status Full Code – Ordered
Diet: Regular Diet – Ordered
— 10/12/22 8:51:00 EDT
DVT PPx: Heparin SC
GI PPx: Protonix
Tele: Yes
Restraints: None
Isolation/Precaution: None
L/T/D: Lines
PIV Forearm Left 20 G 2.5 cm – Peripheral IV Activity: Assessed (10/16/22 07:00:00)

PIV Forearm Right 22 G 2.5 cm – Peripheral IV Activity: Assessed (10/16/22 12:00:00)

Some Progress note about the patient 0n 10/16/22. Please take note of the new changes.

48M PMH HNT, known lung cancer on 2 L nasal cannula (per chart, however per sister had not been on oxygen for the past couple months) w/brain mets now s/p hemicrani and repeat OR for hematoma 5 days ago, now ~2 days with chills, sweats, temperatures 99.9 °F, cough with yellowish thick sputum, fatigue, poor sleep, as well as hemoglobin dropped to 6 now getting 2 units PRBCs transfused by neurosurgery. Per patient and sister at bedside, the symptoms did not start when the patient was admitted or immediately after either operation, but 3 days after her last operation. Blood culture x1 sent, lower extremity Dopplers bilateral and FOBT ordered by neurosurgery team.

BP:(93 – 136)/(53 – 72)HR:(78 – 109)RR:(18 – 30)T:(36.60 – 37.50)

General: Well developed, obese. Denies pain. NAD
Eye: PERRL. No sinus tenderness, Normal appearing conjunctiva.
HENT: moist oral mucosa. Oropharynx clear and without edema, injection nor exudate. Thyroid not enlarged, large cranial scar with many stitches
Neck: non-tender, no LAD
Lungs: On 2 L nasal cannula, crackles at left base, coarse breath sounds, coughing
Heart or Cardiovascular: RRR, no M/R/G. No JVD. Distal pulses strong and equal in all limbs.
Abdomen: Soft, non-distended. No tenderness to palpation. +BS. No masses or organomegaly noted.
MSK: no leg swelling
Skin: Skin is warm, dry. No rashes or lesions. Albinism
Neurologic: ANOx4
Psychiatric: Cooperative, appropriate mood, affect, and thought.

Neuro/Psych — No pain/sedation, ANOX4
Resp –2 L nasal cannula, increased oxygen requirements, no large changes in x-ray possible lobar pneumonia? On antibiotics follow-up cultures procalcitonin; nebulizer Tessalon Perles
Cardio –NAI
Infect –possible pneumonia on top of known metastatic lung disease
Gastro –NAI
Genitourinary/Lytes — Dose medications to GFR.
Heme/Onc –getting 2 units of PRBC, follow-up post transfusion CBC
Endo — BG goal 140-180 mg/dl
Integumentary –hemicrania scar

Lab Results

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 8.2L
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 4.2 4.4 4.0
Chloride 103 95L 98
CO2 31 28 30
BUN 9 10 12
Creatinine 0.70 0.63 0.64
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 1.0 1.0 1.0
PTT 26.7 36.2

10/21/2022 (please these are the most current labs)

WBC = 8.24, Hgb = 9.7L, Hct = 31.1L, platelet = 333, RBC = 3.57L, RDW = 17.1H,
Sodium = 139, Potassium = 3.9, Chloride = 104, CO2 = 28L, BUN = 8L, Creatinine = 0.70, Glucose = 139, Total protein = 6.3, calcium = 8.9, Globulin = 2.6, AST = 41H, ALT = 64H

Lactate (last 3 in 48H)
Lactic Acid Lvl: 1.1 mmol/L (10/16/22 02:10:00)
Lactic Acid Lvl: 2.6 mmol/L High (10/15/22 00:38:00)
Lactic Acid Lvl: 2.8 mmol/L High (10/14/22 21:29:00)

Some full Diagnostic Results

ult Type: CT Chest Abdomen Pelvis wo IV Contrast
Result Date: September 30, 2022 03:42 EDT

* Final Report *

Reason For Exam
Other (Specify)
HISTORY: Brain/CNS neoplasm, staging

FINDINGS:
Anterior right shoulder skin nodularity is partially visualized. Right axillary nodule is 1.5 cm. Calcified mediastinal and hilar lymph nodes are unchanged. No pleural or pericardial effusion is seen. The heart is normal in size.

The dominant bilateral pulmonary masses are grossly stable in size though some of the nodules have enlarged. For example, nodule at the right major fissure superiorly has enlarged from 3.9 to 4.6 cm. There is extensive new interstitial thickening and nodularity within the middle lobe. The left upper lobe and right lower lobe bronchi are occluded by masses.

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. Right mesenteric lymph nodes are mildly enlarged.

No suspicious osseous lesions are identifie

Result Type: MRI Brain wo w Contrast
Result Date: October 02, 2022 16:38 EDT

Reason For Exam
Other (Specify)

REPORT
EXAM: MRI Brain with and without Contrast:

CLINICAL INDICATION: Lung cancer

COMPARISON STUDY: CT dated September 29, 2022

FINDINGS:

A destructive lesion the left parietal calvarium is again seen. There is intra and extracranial extension. The lesion extends to the superior sagittal sinus but does not compromise its lumen. The intracranial extension measures at least 70 mm x 14 mm in depth. There is no significant edema of the underlying brain.

Ventricles are normal in size and position.

No Intra or extra-axial bleeding is noted. The orbits, sella, and craniocervical junction have a normal appearance. Normal signal void is seen in major arterial and dural venous structures.

(10/14/2022 00:56 EDT CT Head wo Contrast)
EXAM: CT of the head without contrast
REASON FOR EXAMINATION:, Cranioplasty

COMPARISON: October 13, 2022

TECHNIQUE:

Axial images were obtained from the skull base to the vertex without intravenous contrast.

FINDINGS:

Patient is status post resection of a bony metastatic lesion in the left parietal region with subsequent cranioplasty. A small amount of blood and surrounding edema is again seen beneath the anterior aspect of the cranioplasty. This measures approximately 10 mm.

Ventricles are normal in size and position. There is no shift of midline structures.

IMPRESSION:

Stable study. [2]

[1] XR Chest 1 View Portable; Ahn, MD, Julia Y. 10/15/2022 12:34 EDT

[2] CT Head wo Contrast; Monsein, MD, Lee Haskell 10/14/2022 00:56 EDT

(10/15/2022 12:34 EDT XR Chest 1 View Portable)
Exam: Radiograph of the chest 1 view

Indication:History of lung cancer

Technique: Single frontal view of the chest

Comparison: 10/13/2022

Findings:Cardiac silhouette is mildly enlarged. Redemonstrated are nodular opacities in keeping with patient’s known metastatic lung disease. Redemonstrated are bilateral perihilar masses. Left lower lobe opacities present. No discernible pneumothorax. Osseous structures are unchanged.

Impression:Stable examination. [1]

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