Progress Note

Patient Name: ‫ﺍﻳﻤﺎﻥ ﻧﺒﻴﻞ ﺍﺳﻤﺎﻋﻴﻞ ﺍﻟﻤﺒﻴﺾ‬ Gender: F

Identity Card: 801742453 Date of Birth: 22/09/1987
Patient Definition Number: 2313061

Date and Time: 13/04/2024 15:07

Attending Specialist: Razan Odeh
Attending MO: Mohammed Abboushi

Patient Clinical Status:

A 36-year-old female patient, with history of:
- Acute Myeloid Leukemia Non M3, S/P AD 3+7 induction (finished 10/2023),
S/P 2 cycles of consolidation HiDAC chemotherapy, last finished in
17/11/2023.
- History of invasive fungal infection in spleen, liver and kidney.
- Right saphenous-femoral junction DVT 11/2023

** Admission diagnosis (ward on 31/12/2023 then to MICU on 30/01/2024,

then to ward on 1/2/2024):
- Acute Myeloid Leukemia Non M3, bone marrow showed remission, had
pancytopenia, day 15 post Cytarabine protocol.
- Sepsis, febrile, due to fungal infection, Entamoeba and Chloridoids
difficile, K. pneumoniae - Carbapenemase producer in blood and central line,
on antibiotics, kept on amphotericin (However NA from the hospital), so
started on voriconazole
- Amphotericin induced hypokalemia, on daily replacement?
- Pancytopenia, out of neutropenia, filgrastim was stopped .
- Hypoxic respiratory failure mostly due to lung edema, on NC 1-2 L, given
stat albumin and furosemide

** Resolved issues:
- Sepsis due to disseminated fungal infection (Aspergillus), will keep on
amphotericin as she starts chemotherapy
- Post laparotomy for resection of infected organs (fungal), on ceftriaxone as
prophylaxis.
- Ruled out extra-pulmonary TB, negative acid-fast stain of peritoneal fluid,
negative QuantiFERON test, negative tissue (spleen) culture
- Type 1 Respiratory failure due to atelectasis post-surgery.
- Left side pleural effusion, pleural kit inserted and complicated with
hydropneumothorax then kit removed, on conservative management.

** Cultures:
- Blood, central and urine cultures 11/4: pending.
- Blood, central and urine cultures 7/4: central and blood gram (-) primary
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- Blood, central and urine cultures (3/4): blood and central showed K.
pneumoniae - Carbapenemase producer
- Blood, central and urine cultures (1/4): urine no growth, blood pending
- Blood, urine and central 26/3: no growth
- Blood (6/3): Clear
- Blood and urine cultures (2/3): Streptococcus mitis/ Comamonas
testosteroni Blood.
- Blood, urine, sputum cultures 5/2/2024: clear
- Mycobacterium tuberculosis and NTM culture (4/2): negative
- Splenic aspiration AF stain (1/2): negative
- Blood, urine, tissue cultures 30/1/2024: Staph. Epidermidis in tissue, clear
others
- Blood and urine culture 27/1/2024: urine CRE K.P, clear blood
- Nasal swap on 25/1/2024: negative
- Blood Culture 24/1/2024. clear
- Splenic aspiration fluid cultures (4/1/2024): Staph Epidermis.

**Isolation: Rectal VRE & CRE.

**Workup:
- Stool C diff and amoeba 3/4/2024
- Bone marrow biopsy and aspiration 14/3/2024
- Splenic Histopathology 30/1/2024: granulomatous lesions with fungal
spores, septate hyphae branching
- Pleural fluids cytology (10/1): negative.

** Vaccinations:
Meningococcal B (27/2/2024)
Pneumococcal PPSV 23 (27/2/2024)

**Imaging:
- Abdomen CT 3/4/2024 cecum and ascending colon, which may suggest
inflammatory/infectious process.
-Abdomen CT scan 21/3: almost resolution of the previously described
hypodense lesions seen in liver.
- Abdominal Ultrasound 4/3: No free fluids
- Follow up Chest and abdomen CT scan 27/2/2024: Significant improvement
of the previously described hypodense lesions seen in liver, and both
kidneys.
- Abdomen US (5/2/2024): mild-moderate free fluid, no focal collections.
- PAN CT scan with IV contrast (27/1/2024) Left pleural effusion with
atelectatic changes, ground glass infiltration seen in inferior lingual segment
of left upper lung lobe. Cardiomegaly decreased amount of pericardial
effusion. Hepatomegaly.
- Chest X ray (25/1/2024): Left sided pleural effusion.
- Brain CT on (17/1): No hemorrhage
- Chest, abdomen and pelvis CT with IV contrast (15/1): The
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hepatosplenomegaly with innumerable tiny hypodense lesions, these

findings may suggest fungal/TB infection or neoplastic infiltration. Filling
defect in right common femoral vein suggestive of thrombosis.
- TTE (6/1/2023): Good LV function (EF by Simpsons: 55%)
- Chest CT without IV contrast (6/1): Left sided pneumothorax, increase in
the amount of left pleural effusion, 1 cm pericardial effusion. Splenic
enlargement with innumerable lesions.
- Chest CT (31/12): left side pleural effusion.

** Procedures:
- PICC line insertion (6/3/2024).
- Laparotomy (Splenectomy, partial gastrectomy, partial hepatectomy, distal
pancreatectomy) (30/01/2024)
- Left Pleural Kit under imaging guidance 27/1/2024 removed on (30/1/2024).
- Right Internal jugular central line (18/1).
- Left Pleural effusion drainage under imaging guidance (8/1), removal
(14/1/2024)
- CT Guided spleen biopsy (4/1/2024).
- Pleural tapping and kit insertion (2/1/2024), removal (4 /12 /2024)
- Right Internal Jugular Central line insertion (31/12), Removed.
- Right Internal Jugular Central line insertion (12/02/2024).
Progress:
The patient was seen and discussed with Dr Razan .

Regarding her sepsis , had multiples sources, she still with recurrent low
grade fever, she was normotensive, still with tachycardia , still pending new
cultures results , labs showed trending up in inflammatory markers,
furthermore she still complaining with diarrhea, she had abdominal
distention without pain, she had mild to moderate dehydration , was kept
on oral vancomycin 500 mg 1*4 and metronidazole IV along with tigecycline
and colistin, also kept on voriconazole as Amphotericin B was unavailable,
was kept on PPN. She started on Bisoprolol 1.25 1*1 PO.

She had hypomagnesemia and hypokalemia (side effects of Amphotericin B

and due to recurrent diarrhea), for which she was replaced accordingly .

On day 15 post chemotherapy, still with anemia and severe

thrombocytopenia and was given 5 units platelets, otherwise she kept on
daily CBC follow up .
Notes:
** Vital signs:
BP 120 / 70 s
Temp 38.4
Pulse: 120s
SPO2: 96 % on NC 2L
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** Physical Examination:
Looks fatigated, conscious, oriented and alert, on room air.
Chest: Good air entry bilaterally with no added sounds
Heart: Regular S1 and S2, no added sounds.
Abdomen: Soft Lax, well healed 15cm midline scar of laparotomy, diffuse
tenderness
Limbs: no lower limbs edema, no erythema or tenderness
Neuro: grossly intact

** Labs:
WBC: 7-2.98 ANC 5.5-2.36 HGB: 7.6-7.1 PLT 3-2
Cr: 0.4 BUN: 12.8
Na: 142.9 K: 3.7 Mg 1.39
CRP: 227-219-198 Albumin 2.2

** Medications:
Amphotericin 50 mg 1x1 IV (7/2) with premedication (Hydrocortisone 150
mg, Paracetamol, Desloratadine)
Voriconazole 200 mg 1*2 PO
Prospan 5 cc 1*3 PO
HTS 3% 3 cc 1*3 neb
Ipratropium bromide 0.25 mcg 1*3 neb
Meropenem 2g 1*3 IV 2/4 made 2 on 4/4 each dose on 3 h
Tigecycline 100 mg 1*2 IV
Vancomycin 500 mg 1*4 PO
Metronidazole 500 mg 1*3 IV
Colistin 4.5 million unit 1*2 IV .
Esomeprazole 40 mg 1x1 PO.
Magnesium sulfate 250 mg 1*2 PO.
Spironolactone 12.5 mg 1x1 PO
Bisoprolol 1.25mg 1*1 PO
Paracetamol 1 gm 1x4 IV PRN
Tramadol 100 mg 1x3 IV PRN
Ondansetron 8 mg 1x3 IV PRN
Dexamethasone eye drops
Multivitamin 1 vial 1*1 IV
Trace element 1 vial 1*1 IV

Input output chart

Diet: soft low bacterial diet
Dextrose 33% 20 cc/h
Amino plasmin 10% 10 cc/h

==========================
** Sepsis due to fungal infection, Entamoeba and Chloridoids difficile, K.
pneumoniae - Carbapenemase producer in blood and central line:
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She was hemodynamically unstable with tachycardia and tachypnea, had

fever with new cultures obtained, her diarrhea is worsening, meanwhile she
is kept on PPN and kept on adequate fluids, electrolytes replacement as
needed along with oral vancomycin and IV Metronidazole, Furter more, her
inflammatory markers are trending down, cultures showed CRE, new cultures
obtained she was kept on meropenem, colistin and IV tigecycline according
to ID team, also kept on Amphotericin B. As there is no Amphotericin in the
hospital, for which kept on Voriconazole.

** Hypoxic respiratory failure:

She was kept on NC 1- 2L, along with nebulizers and prospan for cough,

** Pancytopenia:
On day 15 post her chemotherapy, labs showed pancytopenia, she needs
platelets transfusion, she was kept on daily CBC follow up.

**Diarrhea:
Improving, kept on Vancomycin dose adjusted.

** Acute Myeloid Leukemia

The patient in remission, received 2 cycle of consolidation HIDAC, Cytarabine
protocol day 15 post,

** Post splenectomy:
She was given Meningococcal B and Pneumococcal PPSV 23 vaccines on 27/2,
kept on meropenem, vancomycin and amphotericin.

** Hypokalemia:
Kept on daily follow up and replacement as needed.

** Gastrointestinal prophylaxis:
Esomeprazole 40 mg 1x1 PO

** Right Saphenofemoral junction DVT:

Off Due to low platelets, encouraged to mobilize.

With collegial regards ,

Dr. Mohammed Abboushi

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