Greater Vision wrote/sing "Start With Well Done"- a favorite of mine. I took time to add photos of the first 6 months of 2021. This includes the surprise time spent in hospital for heart and A M Leukemia as well as my recovery up to July. I give God credit for answering prayer. Janice has done a super job to take care of me under Hospice. I would like to thank those who pray for me, those who shared meals, sent cards, mowed our lawn, visited us, as well as the hospital and hospice staff who have been wonderful.
Dr. Julie Smith from last months visit to Dr.
Assessment/Recommendations: 66 y.o. male with AML Monoblastic subtype, with critically illness at presentation and initiation of induction chemotherapy. He was discharged eventually the first week of May has been home with hospice since it in many regards has had substantial improvement in his quality of life and symptom management. He has now eating better, and has at this point a temporary hematologic improvement and stabilization of his white count and platelet count, his anemia is also improved from 3 weeks ago likely due to his improvement in nutrition.However his exam findings are fairly classic today for leukemia cutis. This is not surprising given monoblastic acute leukemia subtype, as monoblastic leukemia has a predilection for soft tissues including soft tissues of the skin, kidneys, other organs, gums, and in patients who develop leukemia cutis this is considered ominous, with impending hematologic relapse. I discussed that this is not a curable condition and treatment with aggressive chemotherapy would be extremely difficult if not harder than he had before. His goals are to not have treatment that would make him weaker or take away from his current quality of life even knowing that his leukemia is terminal.Regarding prognosis it may be that during the next several weeks to 1 or 2 months he would have other signs and symptoms of progressive leukemia such as symptomatic anemia, development of purpura and petechiae, bone pain, etc. Also gum swelling and bleeding from his gums would be something to watch for.He would like to stay on hospice and given his subtype of leukemia, its aggressiveness, and the findings on exam today in addition to noncurative treatment I also recommend that he continue on hospice treatment.
Here are some of the Dr. reports from while I was in hospital;
Note From Your Admission on 04/08/21
Progress Notes by GENEVIEVE O'SULLIVAN, MD at 05/05/21 1034
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Palliative Care Assessment/ Recommendations
Mr. Hendricks is a 66 yo gentleman with AML, with a prolonged and complicated hospital course since admission on 4/8. We have had several goals of care discussions throughout his course, the most recent yesterday. He has communicated with this family, and they are supportive, that he wants to go home, and be on hospice. He holds on to hope that he may get better, though does not desire ongoing medical intervention in the hospital setting. He has made it clear that he knows he will die, and he is comfortable with this.
He is currently stable and able to be cared for at home by his family. Hospice open date is Saturday.
5-4-21
IMPRESSION: 66-year-old man with:
1. AML, status post induction with idarubicin and cytarabine, initial oncologist Dr. Buckley, transitioning to Dr. Smith. His neutropenia has resolved. Platelets have normalized. Hemoglobin is stable from yesterday at 8, although down from 2 days prior 10. He has had a very rough time with this 26-day hospitalization, including extensive time in ICU on the ventilator, as outlined separately, with subsequent intermittent periods of acute hypoxic respiratory failure requiring high flow oxygen. I speak with him briefly about how all this has been for him, he is quite clear that he would not want reintubation in the event of progressive respiratory failure,, but I really have not taken the discussion any further, as there is palliative care meeting with the patient is best previously scheduled for today, see above, with patient expressing wish to transition to comfort measures only after that discussion per Dr. O'Sullivan, who has written those orders for comfort measures and DNR status. Dr. Sullivan will communicate directly Dr. Smith regarding this.
2. Acute hypoxic respiratory failure. Etiology is not entirely clear with persistent hypoxemia. I have personally reviewed his chest x-ray from yesterday, with mild pulmonary vascular congestion with stable mild basilar opacities. He did respond to a dose of furosemide at the time of his high flow requirement, now on 5 L. He had a CT angiogram which was negative for pulmonary embolism on April 10, has not had interval imaging in that regard. His renal function did worsen following that study, and currently his creatinine is 1.62. His LV systolic function was normal on echocardiogram in 4/28. In any event, he does want to focus on comfort only as of the palliative care discussion today, although if in the hospital was more comfortable on high flow he would be okay with that for a short period. He is afebrile, has resolved neutropenia, antibiotics discontinued today, as well as prophylaxis in the setting of wish for DNR only and enrolling in hospice.
3. Ogilvie syndrome. This developed in the setting of a fentanyl infusion in the ICU. He was treated with neostigmine on 4/23 and colonoscopy for decompression on 4/24. Eric continues to have bowel movements, scheduled senna is continued.
4. Cardiac tamponade with cardiogenic shock. About 6 and 50 cc of amber-colored fluid was removed by pericardiocentesis and ultimately he went for a pericardial window and drain placement, drain removed on 4/20, and repeat limited echo on 4/28 with resolution of effusion. He is tachycardic but needs of his overall goals of care have not repeated an echo.
5. Troponin bump up to 2.1 to peak in setting of his critical illness, not further assessed currently. No chest pain today. He was hospitalized in March 2021 with angina symptoms and surprisingly normal coronaries on angiographic evaluation, and was subsequent to that that his AML was diagnosed.
6. Acute kidney injury. Peak creatinine was 3.07. Nephrology followed, signed off on 4/18. Creatinine started rising again on 5/3, lisinopril was discontinued, but he is also diuresed for worsening respiratory flora at the time but creatinine is not coming down, we will not continue to monitor, continue off lisinopril.
7. Severe protein calorie malnutrition. He has been on TPN. He is increasing oral intake of milk shakes today. TPN is discontinued following completion of today's bag as noted above.
8. Subdural hematoma. The timing of onset this is unclear, it was an incidental finding on his CNS imaging, with no progression on follow-up CT on 4/29, Dr. Whitson consulted, no neurosurgical intervention recommended at that time.
9. Possible nephrogenic diabetes insipidus. Fluid management has been difficult, balancing tendency toward volume overload and respiratory failure with renal function, see off service note from Chad McBride from yesterday. In transitioning care with comfort the only goal, not desiring prolongation of life, not following further labs.
10. Melena noted earlier in his stay. Was not on PPI prior to pressure, has been on Protonix during the admission. Platelets have risen, stable H&H from yesterday to today, focusing on comfort, stop surveillance labs.
11. Delirium with critical illness. Although is quite fatigued, appears resolved, able to coherently tell me details about his life, children, etc.
Progress Notes by MORGANNE MCCANN, OT at 05/03/21 0857
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Progress Notes by GENEVIEVE O'SULLIVAN, MD at 04/27/21 1314
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