PREOPERATIVE DIAGNOSES:
1. Left breast mass.
2. Atypia, fine-needle aspiration.

POSTOPERATIVE DIAGNOSIS: Left breast cancer.

PROCEDURES PERFORMED:
1. Left lumpectomy.
2. Left axillary lymph node sampling.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ESTIMATED BLOOD LOSS: 50 mL.

ANESTHESIA: MAC.

TUBES AND DRAINS: 10 mm Blake drain x1.

PROCEDURES PERFORMED:
1. Left lumpectomy.
2. Left axillary lymph node sampling.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed on the OR table in the supine position for lumpectomy and axillary lymph node sampling. Following the administration of IV sedation, the patient’s left breast was prepped with Betadine and draped in the usual sterile manner. Xylocaine 1% without epinephrine was injected overlying the mass at the 2 o’clock position at the left breast.

An elliptical incision was made overlying the mass. Dissection was carried down to the subcutaneous tissue until the mass was identified. Upon reaching the mass, the lesion was removed.

The specimen was marked with a short suture on the superior margin and a long suture on the lateral margin. The specimen was submitted to pathology and an infiltrating ductal carcinoma was identified.

Additional tissue was taken along the superior, inferior, medial, lateral, and posterior margins. The anterior margin was fully excised with the initial specimen.

Upon excising the margins, the clavipectoral fascia was then opened and a lower axillary lymph node dissection was performed removing the axillary fat between the axillary vein and chest wall and the latissimus dorsi muscle.

Vascular and lymphatic channels were clipped as they were encountered. An extensive dissection was not performed. Grossly, these nodes did appear to be negative.

A 10 mm Blake drain was placed through a separate stab incision in the anterior axillary line and anchored into place with a 2-0 silk suture.

The subcutaneous tissue was closed with interrupted 3-0 Vicryl suture and the skin closed with 4-0 Vicryl subcuticular stitch. Hemoclips were left at all margins of the lumpectomy cavity. Benzoin, Steri-Strips, dry sterile gauze and Tegaderm dressing were applied.

All needle and sponge counts were correct. The patient was returned to recovery in good condition.

DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

DIAGNOSES:

1. Malignancy of the bronchial lung.
2. Pleural effusion.
3. Metastatic malignancy to the liver.
4. Ascites.
5. Chronic airway obstruction.
6. Anemia.
7. Diabetes.
8. History of tobacco use.

PROCEDURES DURING THIS ADMISSION: Percutaneous abdominal drainage and injection of chemotherapy.

HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old gentleman with history of a small cell lung cancer treated with both chemotherapy and radiation. He had been in stable condition as of late until about one month ago when he started to develop symptoms of increasing shortness of breath. This has been associated with swelling in his lower extremities as well as development of jaundice.

He presented to the emergency department where he was noted to have a right upper lobe infiltrate and a new right pleural effusion. For that, he was admitted for further evaluation and treatment. Also, complains upon admission of decreased appetite and constipation.

HOSPITAL COURSE: After assessment in the emergency department, the patient was admitted and placed on IV fluids. Labs were obtained, and consult was made to the pulmonary specialist regarding the patient’s diagnoses of lung CA and pneumonia. The patient was placed on the community-acquired pneumonia protocol and treated with IV antibiotics. For management of his diabetes, a consult was made to the endocrine specialist, and he was maintained on nutritional therapy, Accu-Chek monitoring, insulin therapy with evaluation of TSH and hemoglobin A1c. A consult was made to the pulmonary specialist regarding his pleural effusion and shortness of breath. After assessment and evaluation, recommendation was for ultrasound-guided thoracentesis, evaluation of the abdomen for ascites, and oxygen to keep saturation greater than 93%.

On MM/DD/YYYY, the patient also underwent evaluation by bilateral venous Doppler of the lower extremities with no evidence of deep vein thrombosis of the right or left leg noted. He also underwent evaluation for dyspnea with a 2-dimensional echocardiogram. This revealed concentric left ventricular hypertrophy present with normal left ventricular systolic function noted. Abnormal diastolic compliance was seen. No pericardial effusion was noted.

The patient underwent ultrasound-guided paracentesis for his diagnosis of ascites and successful paracentesis was done with removal of about 250 mL of bloody ascitic fluid. CT scan of the brain obtained on MM/DD/YYYY revealed no acute intracranial pathology identified. Current scan appears similar to that of previous done almost 10 months ago. Ultrasound of the chest was ordered with regard to pleural effusion. Ultrasound revealed a small right pleural effusion present. Despite removal of fluid, the patient continued to have dyspnea and shortness of breath.

Discussion was made with the patient and his family with regard to his current condition and overall poor prognosis. He was treated in the past with both chemotherapy and radiation and now presents with pleural effusion and ascites with associated jaundice. The patient was made a DNR with full active treatment and was in agreement to single-agent chemotherapy for salvage chemotherapy. The patient was then treated with single-agent irinotecan (CPT-11), but despite treatment, he continued to have jaundice, elevated bilirubin, and progressive metastatic disease to the liver.

Discussion was made with both the patient and his wife with regard to discharge planning and hospice care. It was the wish of the patient that he return to home to be cared for by family and for hospice consult to be obtained. Social work was consulted with regard to arranging hospice care at home. Once these arrangements were completed and necessary equipment obtained, the patient was then discharged to home under the care of hospice. We will continue to monitor him closely while under the care of hospice at home.

PREOPERATIVE DIAGNOSIS: Adenocarcinoma of the prostate.

POSTOPERATIVE DIAGNOSIS: Adenocarcinoma of the prostate.

PROCEDURE PERFORMED: Prostate brachytherapy.

SURGEON: John Doe, MD

ANESTHESIA: General anesthesia via LMA.

COMPLICATIONS: None.

DRAINS: One 18-French Foley catheter per urethra.

INDICATIONS FOR PROCEDURE: This patient has a new diagnosis of adenocarcinoma of the prostate diagnosed due to a very slowly rising PSA. His current PSA level is only 2.0, but prostate ultrasound biopsies were performed showing adenocarcinoma of the prostate at the left base of the prostate, and two biopsies were positive out of eight with a Gleason score of 6. Treatment options have been discussed, and he wishes to proceed with prostate brachytherapy. Informed consent has been obtained.

DESCRIPTION OF PROCEDURE: The patient was placed on the operating table in the supine position. General anesthesia was administered via LMA. He was then placed in the dorsal lithotomy position and sterilely prepped and draped in the usual fashion. The prostate ultrasound was inserted. The prostate was visualized using the preplanned study as a guide. Prostate brachytherapy was performed. The patient tolerated the procedure well and had no immediate intraoperative or postoperative complications.

We implanted a total of 54 iodine-125 radioactive seeds through 12 needles with each seed containing 0.373 millicurie per seed. During the procedure, the patient received 4 mg of Decadron IV and 400 mg of Cipro IV. Subsequent fluoroscopy showed good distribution of the seeds throughout the prostate. The patient will have a CAT scan of the pelvis and simulation for his seed localization. Total target dose is 14,500 cGy.

The patient will be discharged with prescriptions for Cardura 1 mg a day for a month with two refills and Tylenol No. 3 one t.i.d. p.r.n. for pain, a total of 20, Pyridium Plus one b.i.d. for 10 days, Cipro 500 mg b.i.d. for five days and prednisone 10 mg t.i.d. for a week.

Discharge instructions were explained to the patient and his wife. He will return to see Dr. Jane Doe in two weeks and Dr. John Doe in four weeks for a followup.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Myelodysplastic syndrome and pancytopenia.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old man diagnosed with myelodysplastic syndrome several months ago when he presented with progressive pancytopenia. We have followed him in the office, and unfortunately, despite supportive care with Procrit and intermittent transfusions, his pancytopenia has worsened over time. He has had several hospitalizations for congestive heart failure due to ischemic cardiomyopathy. He is now admitted for right upper extremity cellulitis versus gout versus pseudogout. Since admission, he has undergone treatment with antibiotics and has received transfusion of packed RBCs. The patient continues on weekly Procrit.

PAST MEDICAL HISTORY: As above, atrial fibrillation, chronic renal insufficiency, hyperlipidemia, coronary artery disease, hypertension, ischemic cardiomyopathy, and lumbar stenosis.

SOCIAL HISTORY: The patient is divorced. Smoking: None currently. Alcohol: None.

FAMILY HISTORY: No malignancy.

REVIEW OF SYSTEMS: Positive for chronic shortness of breath, profound weakness, anorexia, fatigue and an itching rash, which is gradually resolving.

PHYSICAL EXAMINATION:
GENERAL: The patient is a frail man, in no acute distress.
VITAL SIGNS: Temperature 97.4, pulse 94 and regular, respirations 16, and blood pressure 120/52.
HEENT: Normocephalic and atraumatic. Oral mucosa is moist.
NECK: Lymph nodes. No palpable supraclavicular, infraclavicular, cervical, axillary, inguinal adenopathy.
HEART: Irregularly irregular.
LUNGS: There are crackles at the bases bilaterally.
ABDOMEN: Bowel sounds are present. The abdomen is soft and nontender without organomegaly.
GENITALIA: Normal external male genitalia.
NEUROLOGIC: No focal deficit.
HEMATOLOGIC: Scattered ecchymosis.
SKIN: Resolving rash on the back, peeling skin on the right hand at the site of previous swelling. Significant for pallor. There is no jaundice.

LABORATORY DATA: BUN 56 and creatinine 1.5. White blood cell count 28,000, hemoglobin 7.2, hematocrit 24.4, and platelets 32,000.

ASSESSMENT:
1.  Myelodysplastic syndrome with worsening pancytopenia. The patient has declined low intensity chemotherapy. We are continuing supportive care with Procrit and transfusions to attempt to keep hemoglobin greater than 7.5.
2.  Ischemic cardiomyopathy.
3.  Rash, resolving.
4.  Right hand cellulitis, improving.
5.  Chronic renal insufficiency.
6.  Coronary artery disease.

RECOMMENDATIONS:  Continue weekly Procrit and transfuse to keep hemoglobin greater than 7.5. Follow up with us next week. Unfortunately, this gentleman’s prognosis is poor. He would be an inappropriate patient for hospice care. His daughter has durable power of attorney for health care. The patient seems to understand the seriousness of his multiple medical problems at this time.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old with myelodysplastic syndrome, on Neupogen and Aranesp. The patient is having terrible, terrible pain in his neck, which he has injured in the past.

REVIEW OF SYSTEMS: LUNGS: Unremarkable. CARDIOLOGY: Unremarkable. GI: Unremarkable. GU: Unremarkable. MUSCULOSKELETAL: Bad neck and back pain, which was chronic. NEUROLOGIC: No new motor deficits. PSYCHOLOGIC: Unremarkable. HEMATOLOGY: Unremarkable.

PHYSICAL EXAMINATION: VITAL SIGNS: Height 66, weight 190 pounds, temp 97.6 degrees, blood pressure 142/72, pulse 74, and respiratory rate 16. HEENT: Eyes: Unremarkable. HEART: Unremarkable. ABDOMEN: Unremarkable. EXTREMITIES: Unremarkable. MUSCULOSKELETAL: Tenderness in the neck area and the muscles are tight in the shoulder area. There is no significant neuro or motor deficit. SKIN: Unremarkable. HEMATOLOGIC: Unremarkable.

LABORATORY STUDIES: Hemoglobin 10.6. WBC count 3.8.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old with myelodysplastic syndrome.
1.  Thrombocytopenia. Platelet count is 239, normal.
2.  Leukopenia. ANC 2.7, WBC count 3.8.
3.  Anemia. Hemoglobin 7. The patient on Aranesp.
4.  Severe night pain. He received Neupogen and Aranesp. We are going to send him for pain management first before giving him more Neupogen. According to the patient, he got deathly sick with severe neck pain.
5.  We will discontinue Neupogen and will give him Leukine.
6.  The patient to see Dr. John Doe as soon as possible.

Hematology Oncology Sample #2

PRINCIPAL DIAGNOSIS: Bone marrow involvement, T-cell lymphoproliferative disorder.

RADIOGRAPHIC STUDY: CT scan of chest, abdomen and pelvis done did not reveal any adenopathy or any masses. She does have a solitary gallstone and renal cortical cyst. Otherwise, unremarkable scan.

INTERMITTENT HISTORY: The patient is here for her six-month followup. Since the last visit, she had back pain and she had fractured vertebrae. She was evaluated at the outside hospital and had kyphoplasty. Also, just a couple of days ago, she was standing on a small stool in her kitchen to reach for an object in the cabinet, she fell backward and she fractured her right arm. There is an x-ray from outside hospital; it showed impacted fracture of the radial neck. She did see Orthopedics.

REVIEW OF SYSTEMS: Her appetite is good. There is no weight loss or loss of appetite. No fever or night sweats. No frequent infection. Her energy is slow, but she said now with the weather, it is getting better. She is not having any fever or night sweats. No unusual headache, difficulty swallowing, chest pain or shortness of breath. No abdominal pain. She does have a bruise from her fall but otherwise no significant changes. The remaining review of systems was completely unremarkable.

PHYSICAL EXAMINATION: GENERAL: She is awake, alert, and oriented. VITAL SIGNS: Stable. HEENT: Within normal limits. There is no lymphadenopathy in the cervical, supraclavicular, axillary or inguinal area. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. ABDOMEN: No organomegaly. EXTREMITIES: Lower extremities: No edema. Upper extremities: She does have some bruises on her right arm, and she has a splint on her right arm. NEUROLOGIC: Examination was intact.

ASSESSMENT AND PLAN: The patient is a pleasant (XX)-year-old Hispanic female with a T-cell lymphoproliferative disorder manifested as large granular lymphocyte leukemia classified as T-cell lymphoproliferation. She does not have any involvement in any of her lymph glands. The CT scan that she had did not reveal any masses or adenopathy. Her skin inspection did not reveal any skin lesions. Today, we will repeat her CBC and see if the counts are stable. We will also review her peripheral blood smear. If the counts are stable, then we will continue to observe her and we will see her in follow up in six months from now.

Hematology Oncology Sample #3

PRINCIPAL DIAGNOSES:
1.  Follicular lymphoma removed from the small intestine.
2.  Abnormal PET scan showed activity in the duodenum, right supraclavicular area, and right parotid area.

RECENT PROCEDURES:  Upper endoscopy and biopsy of the duodenum was completely normal.

INTERIM HISTORY:  The patient is here for a followup visit after she got the PET scan, which showed the activity in the right parotid gland and the right supraclavicular area and the duodenum. She had gone through the upper GI evaluation and the upper endoscopy was completely normal, and the biopsy did not reveal any evidence of lymphoma. We asked her to come for a followup. When we did examine her before, we were not able at that time to feel any lymph node in the right supraclavicular area and that was back in February. She came today. She is feeling well and does not have any specific complaint or problem. No unusual headache. No difficulty swallowing, chest pain, or shortness of breath. No abdominal pain. No fever or night sweats. No weight loss or loss of appetite, but she said for the last week or so, she noted the development of the mass in the right supraclavicular area.

PHYSICAL EXAMINATION: GENERAL: She is awake, alert, and oriented. VITAL SIGNS: Stable. HEENT: Within normal limit. Normocephalic and atraumatic head. The pupils are equal in size. LYMPH NODES: She does indeed have a new lymph node that appeared in the right supraclavicular area; it is around 2 x 3 cm. We did not appreciate any other lymphadenopathy. ABDOMEN: Soft, no palpable masses. No organomegaly. HEART: Regular rhythm. LUNGS: Clear to auscultation and percussion. EXTREMITIES: Lower extremities: No edema. MUSCULOSKELETAL: Unremarkable. SKIN: Unremarkable.

ASSESSMENT AND PLAN:  The patient is a pleasant lady who had small bowel obstruction today due to follicular lymphoma. Now, she has a sudden onset of lymph node in the right supraclavicular area. It is most likely consistent with lymphoma, but we would like to see if it is the same type as her follicular lymphoma or if it is an aggressive type. Definitely, we need to remove the right supraclavicular lymph node and she is going to see Dr. John Doe for this, and based on the pathology, then we would determine the appropriate treatment that is needed. The fact that this lymph node appeared quickly, tells us we need to address the treatment with the systemic therapy. So, this will be done after the lymph node is removed. The above was discussed in detail with the patient and she is in agreement with it.

REASON FOR CONSULTATION: New diagnosis of grade 2 follicular non-Hodgkin lymphoma.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old, otherwise quite healthy female who initially presented to the emergency room with abdominal pain. At the time of her admission, she was found to have significant lower extremity swelling as well as elevated liver function enzymes, creatinine of 1.6, and bilirubin of 2.6. CT scan of the abdomen obtained at the time of admission showed evidence of retroperitoneal adenopathy with associated bilateral hydronephrosis and possible distal common bile duct blockade. Subsequent MRI of the abdomen and pelvis was obtained showing findings concerning for mass at the ampulla with obstruction of the distal common bile duct and pancreatic duct with again noted bilateral hydronephrosis, bladder diverticula, and retroperitoneal adenopathy.

Gastrointestinal consultation was obtained, and although cannulation of the bile duct was attempted, this was not able to be performed. Subsequently, however, she has had improvement in her liver enzyme abnormalities with supportive care. She underwent CT-guided lymph node biopsy. This reveals evidence of a follicular grade 2 non-Hodgkin lymphoma, Ki67 50%, and CD20 positive.

PAST MEDICAL HISTORY: Significant only for previous abdominal surgery, including ventral hernia repair, total abdominal hysterectomy with right-sided oophorectomy and previous appendectomy.

MEDICATIONS: She is on no regular medications.

ALLERGIES: She has no medication allergies.

MEDICATIONS: In the hospital include hydrocodone as needed, amlodipine, Ancef, allopurinol 200 mg daily, Zosyn as needed, and ondansetron.

REVIEW OF SYSTEMS: Negative for fevers, chills, night sweats, nausea, vomiting but positive for poor appetite, positive for abdominal pain, which has improved, positive for lower extremity edema. Negative for skin rash, negative for dysuria, negative for focal neurologic problems.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 166/76, temperature 36.6, heart rate 82, respiratory rate 20, and O2 sat 95% on room air.
GENERAL: This is a pleasant, alert, oriented, elderly female in her hospital bed, in no acute distress.
HEENT: Normocephalic and atraumatic. She has no oropharyngeal lesions or thrush.
LUNGS: Clear.
HEART: Regular rate and rhythm without murmurs, clicks or rubs.
ABDOMEN: Soft and nontender and no masses are palpated.
EXTREMITIES: She has 2+ pitting edema to the knee bilaterally.

LABORATORY AND DIAGNOSTIC DATA: Recent laboratory studies show white count 6.6, hemoglobin 11.8, hematocrit 36.4, and platelet count 284, creatinine 0.9, BUN 24, electrolytes normal, alk phos 190, which is improved, ALT 120, which is improved, AST 88, which is improved. Total bili 3.5, albumin 3.2, LDH elevated at 602, uric acid elevated at 8.8. Radiology results and pathology as above.

IMPRESSION:
1.  Follicular grade 2 non-Hodgkin lymphoma with bulky retroperitoneal and abdominal adenopathy.
2.  Likely incomplete obstruction of common bile duct from underlying lymphoma and adenopathy.
3.  Hydronephrosis, likely secondary to follicular grade 2 non-Hodgkin lymphoma with bulky retroperitoneal and abdominal adenopathy.
4.  Bilateral leg swelling, slightly improved, likely from lymphomatous blockade of venous return.
5.  Elevated uric acid.
6.  Mild normocytic anemia.

PLAN:  We have reviewed her diagnosis, treatment options, prognosis, and goals of care of her grade 2 follicular non-Hodgkin lymphoma. Her age, frailty, and risk of tumor lysis syndrome are substantial. However, her treatment options are generally effective at inducing a response and long-term remission is possible with appropriate therapy. The patient is otherwise healthy, despite her advanced age. We recommended initiation of daily prednisone at 40 mg per day, and we have discussed the initiation of single agent rituximab as a way to induce a treatment response at low risk of tumor lysis syndrome. This may enable a period of improvement that will allow for strengthening and discharge home and may open up additional chemotherapeutic options, which may be more aggressive but result in more prolonged remission, like combination rituximab with bendamustine.

DIAGNOSIS:  Lung cancer, clinical stage T4N0M0, stage IIIB. The patient presented with a mass involving the right lower lobe. This was a clinical diagnosis as a biopsy was felt to be too risky for this patient given her severe chronic obstructive pulmonary disease.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic female with oxygen-dependent COPD who presented with a large right lower lobe mass three years ago. PET/CT at that time revealed a right lower lobe mass with an SUV of 19 with loss of a flat plane between the mass and the bronchial system and the left atrium. The mass was surrounding the right lower lobe bronchus. She had hemoptysis.

The patient underwent a split course of palliative radiation therapy receiving 3000 cGy over 10 fractions followed by a two-week break and an additional 2100 cGy over 7 fractions. All treatments completed two years ago. She is now approaching three years out from completing this palliative course of radiation therapy treatments. She continues to do surprisingly well. She has no hemoptysis. She has baseline dyspnea with exertion. She tries to wear her oxygen as best as she can, but she does not really wear it 24/7. Appetite is stable. Energy level is stable.

REVIEW OF SYSTEMS:  Ten-point review of systems was performed. She notes fatigue, which she scores as a 5 on a scale of 0 to 10. Occasional headaches, occasional earaches. She has hearing loss. She notes swelling in her hands and feet and irregular heart rate. She notes wearing glasses for vision correction, eye disease and blurred vision. Chronic shortness of breath and wheezing. Frequent urination and urinary incontinence. Some abdominal discomfort, occasional nausea and loss of appetite. Joint stiffness and pain, weakness with walking.

CURRENT MEDICATIONS:  Albuterol nebulizer; Neurontin 200 mg morning, 200 mg midday, and 400 mg evening; metoprolol 50 mg one p.o. daily; Lasix 20 mg one p.o. daily; potassium 10 mEq one p.o. daily; Cozaar 100 mg one p.o. daily; prednisone 5 mg one p.o. daily; diltiazem 300 mg one p.o. daily; Coumadin 4 mg one p.o. daily; Lortab 7.5 mg as needed for pain; and Nitrostat 0.4 mg as needed for chest pain.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2, pulse 80, blood pressure 128/72, pulse oximetry 90% on room air. Weight 140 pounds.
GENERAL: The patient looks fairly well.
HEENT: Normocephalic and atraumatic. EOMI. PERRLA. Sclerae are without icterus. Intraorally, her mucosa is smooth and pink without ulceration or exudate.
LYMPH NODE SURVEY: We detect no cervical, supraclavicular, axillary adenopathy on either side.
SKIN: No abnormal nevi, ecchymosis, petechiae, or rashes.
LUNGS: Lung sounds are decreased throughout, but clear. No wheezes or rales noted.
CARDIAC: Reveals an irregular rhythm. No murmur noted.
EXTREMITIES: Without cyanosis, clubbing, edema or deep calf tenderness.
PSYCHIATRIC: Normal mood and affect, appropriate to situation. Normal judgment.

IMAGING STUDIES:  The patient had a CT scan earlier this morning. We were able to review the report as well as the images. She has stable cardiac enlargement. She does have enlargement of the right atrium. She has some soft tissue surrounding the bronchovascular structures in the right lower lobe without mass identified. Minimal infiltrate or atelectasis in the right lower lobe. All findings are stable compared to a CT scan obtained six months ago.

IMPRESSION AND PLAN:  We have reviewed the results of the CT scan with the patient and her daughter. We have told them that all imaging studies are stable. She does not appear to have any progression or recurrence of her lung cancer. She has done amazingly well three years out from palliative course of radiation therapy treatments. We will see her back again in six months with a followup diagnostic chest CT with contrast.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with a history of Lynch syndrome. He has a stage IV colon cancer with metastases to liver and lungs. Recently, he has progressed on FOLFIRI and Avastin. He has recently been evaluated and recommended treatment with HAI. He will proceed with this after the holidays. Today, he has a few complaints. He does note that he has moderate pain in the right side, both right upper and lower quadrants. He currently takes Vicodin 10/325 q. 4 hours for this.

Since he has been taking his pain medicine, he has had some problems urinating. He is no longer able to urinate from a standing position and has to urinate while seated due to inability to initiate the urine stream.

Past medical history, past surgical history, family history, and social history are unchanged from previous dictations.

ALLERGIES AND MEDICATIONS: Reviewed and updated.

REVIEW OF SYSTEMS: A comprehensive 12-point review of systems is otherwise within normal limits.

PHYSICAL EXAMINATION:
VITAL SIGNS: Reveal a heart rate of 144, respiratory rate of 16, and blood pressure is within normal limits.
GENERAL: Alert and oriented x4, in no apparent distress.
HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear. There is no cervical lymphadenopathy.
HEART: There is a noted tachycardia. No murmurs, rubs or gallops appreciated.
LUNGS: Clear to auscultation bilaterally. No wheezing.
ABDOMEN: Slightly tender with no rebound or guarding on the right side of the abdomen.
EXTREMITIES: No edema, no erythema.
SKIN: No rash or lesions.
NEUROLOGIC: Cranial nerves grossly intact.
PSYCHIATRIC: Normal affect and mood.

LABORATORY DATA: No new labs at this time.

IMAGING DATA: No new imaging at this time.

IMPRESSION AND PLAN: The patient is a (XX)-year-old male with history of colorectal cancer and Lynch syndrome as described above. He has recently progressed on FOLFIRI, Avastin and is due to begin therapy with hepatic arterial infusion. We are concerned for his heart rate. He is asymptomatic, and upon further questioning, he also notes some darkening of his urine despite drinking 3 liters of water each day.

We will order a stat. EKG to be performed here in the clinic as well as labs, including CBC, electrolytes, kidney function, and liver function tests and urinalysis with urine and blood cultures as well. We told him that the etiology of his tachycardia could be due to the concomitant infection and have asked that he return to clinic or the emergency room immediately if he feels febrile or has any malaise or other symptoms. This could also be due to pain, which he continues to have despite Vicodin, and we have added a long-acting MS Contin to his regimen 15 mg p.o. q. 12 hours but instructed him that he may take it q. 8 hours if q. 12 hour dosing does not significantly relieve his pain and allow him to take much less Vicodin.

Otherwise, we will have him follow up as scheduled and have him return here in two months for followup. He agrees with this plan. All his questions have been answered to his satisfaction. We will follow up on his EKG and laboratory evaluations.

DATE OF DISCHARGE: MM/DD/YYYY

ADMISSION DIAGNOSIS: Neutropenic fever.

DISCHARGE DIAGNOSES:
1. Neutropenic fever.
2. Acute myelogenous leukemia, status post induction and three cycles of high-dose Ara-C.
3. Thrombocytopenia.
4. Diarrhea.
5. Vaginal bleeding.
6. Hypokalemia.

PROCEDURES PERFORMED:
1. Two-view chest x-ray.
2. One unit of PRBC transfusion.

HOSPITAL COURSE: The patient is a very pleasant (XX)-year-old female with acute myelogenous leukemia who has undergone three cycles of high-dose Ara-C. She was transferred here after she presented to an outside facility with a one-day onset of fevers and chills. She had a measured temperature at the outside hospital at that time of 102 degrees. She was transferred to this facility and admitted to the oncology service.

She was initially placed on cefepime, and blood cultures were drawn. All cultures throughout the course of her hospitalization turned out to be negative. She, however, remained febrile for the majority of her hospitalization. Upon presentation, she did complain of one-day onset of profuse watery diarrhea that was extremely foul smelling. Of note, she was on p.o. prophylactic Levaquin due to her neutropenia. She was also on prophylactic acyclovir. Due to her being on antibiotics and history of diarrhea, a stool PCR was collected but resulted negative. Before the stool PCR resulted, she was placed on Flagyl as empiric coverage for suspected C. diff colitis. After the stool PCR resulted negative, Flagyl was discontinued.

During the short 24 hours when she was on Flagyl, she seemed to have defervesced, and her fever curve trended down. However, after the Flagyl was discontinued, she started having worsened diarrhea and the fevers went back up again. For this reason, a C. diff PCR was ordered and the Flagyl was resumed. The C. diff PCR was also negative. Until that point, she remained on cefepime and the Flagyl was also decided to be continued since the patient seemed to improve with it. The thinking was that she may have had some colitis that was not related to C. diff.

Six days into her hospitalization, she continued to have fever. At this juncture, vancomycin was added to see if this would help. Repeat blood cultures were negative. Cultures were even drawn from the port that she had. There was some discussion as to whether her fevers may have been caused by the cefepime. The cefepime was discontinued. At this time, however, her fever curve had already started slightly trending down. Over the next 48 hours, she remained afebrile.

The vancomycin and Flagyl were discontinued the day before discharge, and she remained afebrile that night. Her diarrhea had resolved over the last four to five days of her hospitalization and she received Imodium for this. The remainder of her hospitalization was unremarkable and she felt well. Of note, she did complain of poor appetite. We advised her to try to eat as much as she can and at the very least remain hydrated with Gatorade, and she understood that it may take some time for her appetite to completely return to normal.

She did frequently have hypokalemia and hypomagnesemia. This was presumed to be secondary to the diarrhea. Both of these electrolytes were replaced appropriately. However, even after the diarrhea resolved, she continued to have hypokalemia despite replacement. She later notified us that this issue is not new and that she actually takes potassium supplementation at home. She reported that she had p.o. potassium chloride at home and that she did not need medication or a refill for this. She could not, however, recall the dosage. We do not know the etiology of her hypokalemia as this was not worked up while she was inpatient due to again thinking that her hypokalemia was a result of her diarrhea.

Additionally, the patient also had complaints of vaginal bleeding. She was actually admitted previously for the same complaints. OB-GYN was consulted and they recommended discontinuation of her combination oral contraceptive pills and placed her on norethindrone three times a day until her bleeding stopped and then once a day. She reported that she may not have been taking the norethindrone after she was discharged from her last hospitalization. She was placed on this medication, and her vaginal bleeding stopped within one to two days. On the day of discharge, she was advised that she could take this medication now just once a day. On the day of discharge, she was also instructed to resume her prophylactic Levaquin and acyclovir.

DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg p.o. b.i.d.
2. HCTZ 25 mg p.o. daily.
3. Lopressor 25 mg p.o. b.i.d.
4. Pravastatin 10 mg p.o. at bedtime.
5. Norethindrone 5 mg p.o. daily.
6. Levaquin 500 mg p.o. daily.
7. Zofran 4 mg sublingually q.8 hours p.r.n. nausea.
8. Norco 5/325 one tablet p.o. q.4 hours p.r.n. pain.

FOLLOWUP APPOINTMENT: Dr. John Doe in one week for followup for chemotherapy.

FOLLOWUP LABS AND STUDIES: CBC, CMP before appointment with Dr. John Doe.

DISCHARGE DIET: Regular as tolerated.

DISCHARGE ACTIVITY: As tolerated.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Continued management of carcinoma of the lung.

HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old gentleman with a history of non-small-cell carcinoma of the lung. He has undergone radiation therapy and is now receiving chemotherapy in the outpatient setting. He presented in the office for a followup. He was extremely short of breath and was found to have an oxygen saturation of 84%. He did not respond to oxygen via nasal cannula. He was placed on an oxygen mask at 4 liters per minute. His oxygen concentration normalized at 98-100%. Unfortunately, with any speaking or any movement whatsoever, the patient continued to desaturate. He was taken immediately to the emergency department. He is now admitted for shortness of breath and is under the excellent care of the attending physician. Consultation has been placed also to Dr. Jane Doe. The patient denied headache, blurred vision or double vision. He is without nausea, vomiting or diarrhea. He does complain of generalized weakness. He has also completed oral antibiotic therapy for pulmonary infection within the past month. He has also undergone Taxol chemotherapy and at one point was on prednisone. He has been tapered from his prednisone approximately two weeks ago. He was most likely admitted with a pneumonitis; however, further treatment recommendations will be made by Dr. Jane Doe as well.

PAST MEDICAL HISTORY: Significant for carcinoma of the lung. The patient also has degenerative joint disease. He has a history of coronary artery disease. He has been recently diagnosed with type 2 diabetes mellitus.

PAST SURGICAL HISTORY: Positive for Port-A-Cath placement and coronary artery bypass graft.

MEDICATIONS: Please see the records for complete list of home medications.

ALLERGIES: None.

REVIEW OF SYSTEMS: Negative for headache, blurred vision or double vision. The patient has significant shortness of breath. He has a frequent cough. He is expectorating white mucus. He is denying fever, chills, night sweats, nausea, vomiting or diarrhea. He is denying chest pain. He complains of significant weakness. He denies neurological complaints.

PHYSICAL EXAMINATION: Reveals an alert and oriented gentleman who was quite short of breath on immediate presentation. His oxygen saturation was 84%. His saturations recovered to 100% on oxygen via mask. His lungs were diminished, but clear, without wheezing, rales or rhonchi. His heart was slightly tachycardic upon presentation; however, his heart rate returned to normal rate and rhythm once his oxygen had normalized. He is alert and oriented. His neurological examination is nonfocal. His abdomen is benign. His extremities are free of edema, clubbing or cyanosis.

ASSESSMENT AND PLAN: Non-small-cell carcinoma of the lung, status post radiation therapy, now on chemotherapy with severe shortness of breath. The patient is admitted under the excellent care of the attending physician. He is most likely suffering from an exacerbation of pneumonitis. His last chemotherapy was approximately one week ago. The chemotherapy will be placed on hold until resolution of his shortness of breath.