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Associated Diagnoses: None

Allergies : Nil Known allergies

VISIT SUMMARY

ADMISSION SUMMARY

Presenting Problems

Fever immunosuppressed pt

PRINCIPAL DIAGNOSIS

Pseudomonas sepsis

transfusion support for pancytopaenia post chemo

febrile neutropaenia

deconditioning requiring physio

bony pain

Mucositis

Past History and Co-morbidities: Not requiring changes to treatment

Pmhx

- Relapsed Multiple Myeloma ( t11,14), monosomy 13 and TP53 deletion -IgG kappa - initially diagnosed June 2014

Autologous stem cell transplant (ASCT on 14/1/15); on zometa 4mg, biochemical relapse 10 months post transplant - lenalidomide 25mg

Relapse end of July 2016 – CyBorD; relapsed 5/10/17

Start CYBORD 6/11/17 (Cyclophosphomide, Bortezomib and Dexamethasone)

Dex/Polamidamide from 7/12/17

- Hepatitis B core Ig positive

- T2 Diabetes Mellitus + steroid induced hyperglycaemia

- Steroid induced cataracts

- Repair of umbilical hernia 13/9/17

- Bells palsy right side

- Recent CNS plasmocytoma - On radiotherapy

Summary of Progress

Thankyou for your care of Mr.X who presented with fevers and sepsis

He was unwell with mouth ulcers and mucositis post recent PCAB chemotherapy. He was very lethargic with pancytopaenia. BLood cultures were positive for pseudomonas. He was treated with 7 days of tazocin and then deescalated to ciprofloxacin.

During the admission he complained of widespread bony pain, particularly left leg below knee. CT scan did not reveal any severe lytic lesion to explain pain below knee. Doppler US was negative for DVT.

CT chest revealed a large pleural based mass, most likely plasmacytoma as well as multiple lytic skeletal lesions.

He was commenced on targin with good effect.

Serum free kappa light chains were 500 which was reduced from 1000 previously.

He was very deconditioned and required several days of physiotherapy. He was mobilising with a walking stick on discharge.

Plan:

F/U with Haematologist

Continue analgesia with aperients

community pall care link on DC

Medications

Lamivudine 100mg daily

Ranitidaine 300mg daily

Bactrim Forte one tab daily

Gliclazide 60mg BD

Metformin 1g BD

Lipidil 145mg daily

Valaciclovir 500mg daily

Rosuvastatin 15mg daily

Candesartan 32/1.25mg daily

ADVERSE REACTIONS & ALERTS

Allergies

Allergic Reactions (Selected)

NKA

INTERVENTION & RESULTS

Procedures this Admission

Non Theatre Procedures

Procedure: Date:

Chest Routine CT

=========== REPORT TEXT ===========

CT Chest with Contrast

Performed on 02-JUL-2019, 09:51 AM

Clinical History: CH: 69 M ; background multiple myeloma, last chemo Friday 21/06; presented to ED yesterday with fevers and weakness; febrile to 38.8; CXR shows large rounded opacity right mid to lower zone ; ?extrapleural mass ; ?plasmocytoma ; ?other cause ; to furhter characterise with routine CT chest GCH: hypercholesterolemia; niguinal hernia :

Technique:

CT chest with IV contrast.

Comparison:

CT skeletal survey 27 March 2018

Findings:

The large pleural based lesion identified on the recent x-ray corresponds to a soft tissue lesion arising from and destroying the right 5th rib and measures approximately 7 x 4 x 6.6 cm (Se601;Im58). This represents marked interval progression of a likely myelomatous deposit identified on the previous CT skeletal survey.

Numerous other soft tissue skeletal destructive lesions are identified as below:

1. Right 2nd rib anteriorly 13x8mm - markedly decreased in size (36x21mm)

2. Right 3rd rib anteriorly 7mm - new, right 6th rib anteriorly - new, right 8th rib laterally 11mm -new, right 9th rib 12mm - new

3. Right 11th rib - posteriorly - stable.

4. Left 4th rib two foci of soft tissue - new, left 5th rib anteriorly 10mm - new, left 6th anteriorly - new, left 7th posteriorly, 8th rib multiple foci, 9th rib multiple foci - new

New soft tissue lesion at the left lamina and pedicle of the T3 vertebral body (Se601;Im14).

There is early encroachment upon the left posterolateral spinal canal and adjacent 90 degrees contact of the left thecal sac.

Spinal canal is preserved in the reminader of the visualized aspects thoracic spine.

T8 right-sided vertebral body soft tissue deposit with infiltration of the right neural exit foramen (series 603; image 53) - progressed since previous imaging.

Significant interval progression of the soft tissue lesion affecting the sternum with deformity and depression toward the anterior mediastinum.

Numerous well-defined lytic lesions are identified throughout the thoracic spine - mild interval progression.

Left scapula deposit has increased in size. Right scapula appearance is unchanged.

Numerous foci of old fractures and endosteal scalloping in keeping with marrow change is noted.

Pulmonary arteries are patent.

No pericardial effusion.

No thoracic lymphadenopathy.

Small calcified granuloma in the inferior aspect of the left upper lobe.

Bibasal atelectatic bands are noted.

Small bilateral pleural effusions with overlying atelectasis.

Partially visualised upper abdomen and pelvis are within normal limits.

Conclusion:

1. Pleural based lesion identified on the recent chest X-ray is representative of significant interval enlargement of a previously noted myelomatous deposit.

2. Significant interval progression of multifocal thoracic cage and axial skeletal lesions.

3. Please correlate clinically for any radiculopathy regarding the left T3 and right T8 thoracic vertebral deposits which encroach upon the spinal canal and neural exit foramen respectively.

Results

Pending Results

_Antibody Comment - 10/07/2019

_POSITIVE ANTIBODY SCREEN - 10/07/2019

Contact Numbers for Diagnostic Departments:

CONTINUED CARE RECOMMENDATIONS

Follow up Requirements for:

Outpatient Clinic Appointments

Appointments

.

Person to contact regarding this Discharge:

(Trainee Specialist) : Position Registrar.