Notes

60M smoker hx of UCC s/p TURBT 2 years ago [05/24/2017 at VA Long Beach,
pathology showed high grade pT1 UCC (no muscle in specimen)], subsequently
incarcerated for 11 mo and lost to f/u, recurrent symptoms 3/2019, with
worsening AKI and hydroureteronephrosis 7/2019 s/p stent 8/7 and TURBT 8/8/19,
s/p cisplatin and gemcitabine 8/30/19, presented to ED 9/6/19, admitted for
fever, urosepsis, and AKI. Heme/onc service consulted for thrombocytopenia and
normocytic anemia.

Onc history
- Initially diagnosed in 2017, had TURBT 5/24/17, no muscle in specimen
- Lost to follow-up due to incarceration
- 3/19 began noticing hematuria, progressively worsening
- 7/2/19 CT Urogram performed, large bladder mass seen w/ bilateral hydro and
sclerosis vs met seen in T10 vertebral body
- 8/5-8/10/19 Admission for AKI. CT chest/A/P with bladder mass, 3mm RUL pulm
nodule, NaF with nonspecific sclerosis within T10 vertebral body and right
anterior 6th rib. S/p nephrostomy tube for severe left sided hydronephrosis.
Underwent TURBT, path with invasive high grade urothelial carcinoma with
invasion of muscularis propria.
- 8/30/19: C1D1 of cisplatin and gemcitabine
- 9/6/19: Presented to infusion center for C1D8 gemcitabine, but was noted to
have fever, referred to ED for fever, admitted for urosepsis and AKI.

At heme/onc clinic appointment on 8/5 was sent to ED for worsening AKI (1.81
7/2019 from previously normal baseline in 4/2019). During that admission he had
a CT A/P performed which showed severe left hydroureteronephrosis likely 2/2
bladder mass 7.4 x 3.1 x 6.6 cm with likely involvement of left ureterovesicular
junction. 3 mm RUL pulm nodule seen, no other suspicious lesions. PET scan
performed on 8/7 which showed Nonspecific sclerosis within the T10 vertebral
body and the right anterior 6th rib demonstrating increased tracer activity with
indeterminate etiology. His creatinine on admission was 1.89 8/5/19, which
improved after nephrostomy tube placement on the left on 8/7, and TURBT on 8/8
to 1.51. 1.38 on 8/20 labs.

Following that discharge, patient had significantly improved hematuria, but
continue dpain on urination. No fever, chills, or other systemic signs of
infection. On 9/6/19, patient was sent to ED from outpatient chemotherapy
infusion clinic. He was reporting subjective fevers and chills that started
yesterday. He has not taken anything at home to break the fever. He also
reported an associated decrease in urine output via bladder/urethra (patient
estimates less than 400 mL per day, normal is double that or more); no change in
urine output from nephrostomy tube (estimated 1L per day).

UA on admission had large blood noted in urine, though not gross hematuria.
Patient was initially treated with CTX, changed to Zosyn on 9/7/19. Patient
symptomatically improved with improving AKI. Heme/onc consulted due to noted
worsening anemia and thrombocytopenia. No active bleeding noted during hospital
stay.