Encounter for antineoplastic chemotherapy Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes Secondary malignant neoplasm of other specified sites Malignant neoplasm of penis unspecified Unspecified asthma uncomplicated Essential (primary) hypertension Hyperlipidemia unspecified Rheumatoid arthritis unspecified
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
___
 
Attending: ___
 
Chief Complaint:
Scheduled Chemotherapy
 
Major Surgical or Invasive Procedure:
None this hospitalization.
 
History of Present Illness:
Mr. ___ is a ___ male with poorly 
differentiated penile squamous cell carcinoma s/p partial 
penectomy in ___ with rapid metastatic recurrence to soft 
tissue and RP nodes who presents for cycle 3 of TIP.

He is feeling well. He notes occasional dizziness and mild 
numbness in his fingers. He denies fevers/chills, headache, 
vision changes, weakness, shortness of breath, cough, 
hemoptysis, chest pain, palpitations, abdominal pain, 
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, 
dysuria, hematuria, and new rashes.
 
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: reported penile pain and bleeding to his PCP present 
for about 2 months.
- ___: CT torso showing no clear metastatic disease.
- ___: Distal partial penectomy, path showing poorly 
differentiated squamous cell carcinoma with sarcomatoid and 
acantholytic features, pT3. Dr. ___ inguinal 
___ on ___ but patient had some difficult social circumstances 
as he was primary caretaker for his wife. 
- ___: At follow-up visit, he had a new 2x2 cm lesion in the 
left groin.
- ___: CT pelvis showing extensive new retroperitoneal 
lymphadenopathy and new rim enhancing metastasis in the 
pre-pubic fat to the left of midline. 
- ___: Initial med onc evaluation, planned to complete 
restaging and begin palliative TIP, for which patient consented.
- ___: C1D1 TIP
- ___: C2D1 TIP

PAST MEDICAL HISTORY:
- Metastatic Penile SCC with sarcomatoid and acantholytic 
features, as above
- Rheumatoid Arthritis previously treated with Plaquenil, MTX, 
sulfasalaine, leflunomide
- Type 2 Diabetes Mellitus
- Asthma
- +PPD and +Quantiferon, s/p 3 months of INH but complicated by 
LFT abnormalities, then s/p full course of rifampin
- Osteoarthritis
- Right Bundle Branch Block
- Ventral Hernia
- Hypertension
- Hyperlipidemia
 
Social History:
___
Family History:
Mother deceased at ___. Father deceased at ___ from blood cancer. 
No family history of colon, lung, or prostate cancer.
 
Physical Exam:
========================
Discharge Physical Exam:
========================
 
VITAL SIGNS: ___ 0807 Temp: 98.2 PO BP: 121/68 HR: 66 RR: 
18
O2 sat: 100% O2 delivery: ra 
General:  NAD
HEENT:  MMM 
CV:  RR, NL S1S2 no S3S4, no MRG
PULM:  CTAB, respirations unlabored 
ABD:  BS+ SNT/ND
LIMBS:  No ___, WWP
SKIN:  No rashes on extremities
NEURO:  Speech fluent, strength grossly intact, ambulating in
hallway well
PSYCH: thought process logical, linear, future oriented
ACCESS: chest port site intact w/o erythema, accessed and
dressing C/D/I

 
Pertinent Results:
===============
Admission Labs:
===============
___ 02:03PM BLOOD WBC-9.2 RBC-3.14* Hgb-9.5* Hct-29.2* 
MCV-93 MCH-30.3 MCHC-32.5 RDW-18.0* RDWSD-60.0* Plt ___
___ 02:03PM BLOOD Neuts-70.0 ___ Monos-6.8 Eos-1.5 
Baso-0.8 Im ___ AbsNeut-6.45* AbsLymp-1.91 AbsMono-0.63 
AbsEos-0.14 AbsBaso-0.07
___ 02:03PM BLOOD ___ PTT-31.5 ___
___ 02:03PM BLOOD Glucose-174* UreaN-12 Creat-0.9 Na-139 
K-4.8 Cl-100 HCO3-28 AnGap-11
___ 02:03PM BLOOD ALT-12 AST-18 AlkPhos-157* TotBili-<0.2
___ 02:03PM BLOOD Calcium-9.6 Phos-3.5 Mg-1.7

___ 03:38AM BLOOD WBC-11.3* RBC-2.97* Hgb-9.0* Hct-27.6* 
MCV-93 MCH-30.3 MCHC-32.6 RDW-19.1* RDWSD-64.3* Plt ___
___ 03:38AM BLOOD Glucose-188* UreaN-9 Creat-0.8 Na-142 
K-4.6 Cl-110* HCO3-23 AnGap-9*
___ 03:38AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
___ 03:38AM BLOOD ALT-11 AST-___ w/ HTN, DL, Asthma, T2DM, RA, and poorly differentiated 
penile SCC s/p partial penectomy ___ now w/ rapid metastatic 
recurrence presenting for C3 TIP

# Metastatic Penile Squamous Cell Carcinoma 
Unfortunately his high risk localized disease has rapidly
progressed to at least soft tissue and RP nodes. He is being
treated with TIP with palliative intent ___ JCO ___.
He tolerated it well other than fatigue and decreased appetite. 
- required 2L NS boluses to maintain ___ ___
- clinic appointment scheduled for neulasta tomorrow
- restaging imaging tomorrow 

# T2DM
We hold home antihyperglycemics and required about 10U insulin 
despite dex. In concern for potential hypoglycemia at home, we 
downtitrated his home regimen
- stopped glipizide as has poor po intake
- decreased home metformin from 1000 bid to qd and only w/ food
- he will keep a log of sugars and review w/ his outpatient 
oncologist

# Asthma: quiescent, cont advair/flonase, albuterol prn
# HTN: cont ACEI and ASA
# DL: held statin while actively receiving chemo
# RA: on prn oxy, a refill for 14 day supply given

FEN: Regular diet
DVT PROPH: Enoxaparin inpatient
ACCESS: PORT
CODE STATUS: Full code, presumed   
DISPO: Home today w/o services
BILLING: >30 min spent coordinating care for discharge 
________________
___, D.O.
Heme/Onc Hospitalist
p: ___

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of 
breath/wheezing 
2. Aspirin 81 mg PO DAILY 
3. Docusate Sodium 100 mg PO BID:PRN constipation 
4. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID 
5. Lisinopril 10 mg PO DAILY 
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - 
Moderate 
7. Vitamin D 1000 UNIT PO DAILY 
8. Atorvastatin 40 mg PO QPM 
9. GlipiZIDE XL 5 mg PO DAILY 
10. Dexamethasone 4 mg PO ASDIR 
11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 
12. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 
13. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal 
congestion 

 
Discharge Medications:
1.  MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 
take ONLY once a day if you are eating meals. do not take if not 
feeling well and not eating much    
2.  Albuterol Inhaler 2 PUFF IH TID:PRN shortness of 
breath/wheezing  
3.  Aspirin 81 mg PO DAILY  
4.  Atorvastatin 40 mg PO QPM  
5.  Dexamethasone 4 mg PO ASDIR  
6.  Docusate Sodium 100 mg PO BID:PRN constipation  
7.  Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal 
congestion  
8.  Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID  
9.  Lisinopril 10 mg PO DAILY  
10.  Ondansetron 8 mg PO Q8H:PRN nausea/vomiting  
11.  OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - 
Moderate 
RX *oxycodone 5 mg 2.5-5 mg by mouth q4hrs prn Disp #*28 Tablet 
Refills:*0 
12.  Vitamin D 1000 UNIT PO DAILY  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis:
- Encounter for Chemotherapy
- Metastatic Squamous Cell Carcinoma of the Penis
- Secondary Neoplasm of Soft Tissue
- Secondary Neoplasm of Lymph Nodes
- DMII
- Hypertension
- Hyperlipidemia
- Asthma
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 
Discharge Instructions:
You tolerated your chemotherapy well. Please follow up with your 
oncology team as instructed. 

You needed a small amount of insulin despite receiving steroids. 
You may not need a lot of diabetes medications as you have in 
the past. Keep a log of your sugars at home and review them with 
your oncologist in clinic. We decreased your metformin to once a 
day and stopped your glipizide. You should talk to your 
oncologist about whether you need to take atorvastatin. 
 
Followup Instructions:
___

{'dizziness': ['Metastatic Squamous Cell Carcinoma of the Penis'], 'mild numbness in fingers': ['Metastatic Squamous Cell Carcinoma of the Penis'], 'fevers/chills': [], 'headache': [], 'vision changes': [], 'weakness': [], 'shortness of breath': ['Asthma'], 'cough': [], 'hemoptysis': [], 'chest pain': [], 'palpitations': [], 'abdominal pain': [], 'nausea/vomiting': ['Ondansetron'], 'diarrhea': [], 'hematemesis': [], 'hematochezia/melena': [], 'dysuria': [], 'hematuria': [], 'new rashes': []}