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 Essential (primary) hypertension Hyperlipidemia unspecified Type 2 diabetes mellitus without complications Unspecified asthma uncomplicated Rheumatoid arthritis unspecified
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
___
 
Attending: ___
 
Chief Complaint:
Encounter for chemotherapy
 
Major Surgical or Invasive Procedure:
Port Placement ___

 
History of Present Illness:
Mr. ___ is a pleasant ___ w/ HTN, DL, Asthma, T2DM, Rheumatoid
arthritis, and poorly differentiated squamous cell carcinoma s/p
partial penectomy in ___ (pT3, sarcomatoid and acantholytic
features), now with rapid metastatic recurrence to at least soft
tissue and RP nodes who is presenting for a PORT placement
followed by chemo. He states he has been doing otherwise well 
w/o
any F/C, no N/V, no CP/SOB. He had pain at the surgical incision
in his penis but that has resolved. He has pain in his low back
for which he takes oxycodone prn. 

 
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
-___: CT torso showing no clear metastatic idsease
-___: 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.

PAST MEDICAL HISTORY (per OMR):
ASTHMA                                                          
DIABETES TYPE II                                                
PPD POSITIVE                                                    
RHEUMATOID ARTHRITIS previously treated with Plaquenil, MTX,
sulfasalaine, leflunomide. 
+PPD and +Quantiferon, s/p 3 months of INH but complicated by 
LFT
abnormalities, then s/p full course of rifampin                  

Osteoarthritis in left knee
RIGHT BUNDLE BRANCH BLOCK                                       
VENTRAL HERNIA                                                  
NORMOCYTIC ANEMIA                                               
HYPERTENSION                                                    
HYPERLIPIDEMIA                                                  
PENILE CANCER 

 
Social History:
___
Family History:
Father had blood cancer, no history of colon, lung or prostate
ca, no history of stroke or MI
 
Physical Exam:
VITALS: ___ 1154 Temp: 98.2 PO BP: 113/68 HR: 77 RR: 18 O2
sat: 99% O2 delivery: RA 
General:  NAD, resting in bed comfortably
HEENT: MMM, no OP lesions 
CV: RRR, +S1S2 no S3S4, no m/r/g
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs, no suprapubic
tenderness, no CVAT
LIMBS: WWP, no ___, no tremors
SKIN: port site dressing C/D/I
NEURO: CN III-XII intact, strength b/l ___ intact
PSYCH: Thought process logical, linear, future oriented
ACCESS: R chest port
 
Pertinent Results:
Admission Labs:

___ 08:15PM BLOOD WBC-8.1 RBC-3.73* Hgb-11.1* Hct-34.0* 
MCV-91 MCH-29.8 MCHC-32.6 RDW-13.9 RDWSD-46.3 Plt ___
___ 08:15PM BLOOD Neuts-57.9 ___ Monos-5.3 Eos-4.0 
Baso-0.9 Im ___ AbsNeut-4.68 AbsLymp-2.56 AbsMono-0.43 
AbsEos-0.32 AbsBaso-0.07
___ 08:15PM BLOOD Glucose-100 UreaN-10 Creat-0.8 Na-139 
K-4.5 Cl-101 HCO3-27 AnGap-11
___ 08:15PM BLOOD Albumin-4.0 Calcium-10.1 Phos-3.4 Mg-1.9

Labs at time of discharge:

___ 05:38AM BLOOD WBC-6.6 RBC-3.34* Hgb-9.8* Hct-30.2* 
MCV-90 MCH-29.3 MCHC-32.5 RDW-14.4 RDWSD-47.1* Plt ___
___ 05:38AM BLOOD Neuts-64.4 ___ Monos-2.3* 
Eos-0.6* Baso-0.2 Im ___ AbsNeut-4.26 AbsLymp-2.11 
AbsMono-0.15* AbsEos-0.04 AbsBaso-0.01
___ 05:38AM BLOOD Glucose-110* UreaN-9 Creat-0.8 Na-140 
K-4.1 Cl-106 HCO3-26 AnGap-8*
___ 05:38AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.8

Micro:
Urine Cx (___):

   REFLEX URINE CULTURE (Preliminary): 
      GRAM NEGATIVE ROD(S).    >100,000 CFU/mL. 
 
Brief Hospital Course:
___ w/ HTN, DL, Asthma, T2DM, RA, and poorly differentiated 
penile SCC s/p partial penectomy ___ now w/ rapid metastatic 
recurrence presenting for PORT placement and chemo. Patient 
underwent port placement on ___ and started his first cycle 
of chemotherapy as an inpatient which was well tolerated. 
Patient was instructed to follow up in ___ clinic for 
continued monitoring.

# Metastatic Penile Squamous Cell Carcinoma 
Met to at least soft tissue and RP nodes. Started TIP chemo as
follows:
- ___
- Taxol 175 mg/m2 over 3 hours on D1
- Ifosfamide 1200 mg/m2 on D ___ w/ mesna
- Cisplatin 25 mg/m2 on D1-3
- received IVF 500cc boluses pre/post cisplatin
- cont oxy prn w/ colace 
- plan for neulasta as outpatient on ___
- discharged with 4 days of dexamethasone 4mg BID given 
possibility of significant nausea with this regimen, will also 
send with PRN Zofran 

# Asympatomatic Bacturia
- UCx with >100k GNR on routine screening UA
- patient without symptoms at time of discharge and as such will 
not treat
- advised with strict return precautions if patient develops
symptoms of UTI

# T2DM: held home antihyperglycemics, ISS, resume on discharge
# Asthma: quiescent, cont advair/flonase, albuterol prn
# HTN: held ACEI while on chemo, as well as ASA
# DL: held statin while on chemo
# RA: on prn oxy
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea  
2. Atorvastatin 40 mg PO QPM 
3. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID 
4. Fluticasone Propionate NASAL 1 SPRY NU BID 
5. GlipiZIDE XL 5 mg PO DAILY 
6. Lisinopril 10 mg PO DAILY 
7. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 
8. OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain - 
Moderate 
9. Aspirin 81 mg PO DAILY 
10. Vitamin D 1000 UNIT PO DAILY 
11. Docusate Sodium 100 mg PO BID 

 
Discharge Medications:
1.  Dexamethasone 4 mg PO Q12H Duration: 4 Days 
take after chemo 
RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp #*8 
Tablet Refills:*0 
2.  Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours 
Disp #*12 Tablet Refills:*0 
3.  Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea   
4.  Aspirin 81 mg PO DAILY  
5.  Atorvastatin 40 mg PO QPM  
6.  Docusate Sodium 100 mg PO BID  
7.  Fluticasone Propionate NASAL 1 SPRY NU BID  
8.  Fluticasone-Salmeterol Diskus (250/50)  1 INH IH BID  
9.  GlipiZIDE XL 5 mg PO DAILY  
10.  Lisinopril 10 mg PO DAILY  
11.  MetFORMIN XR (Glucophage XR) 1000 mg PO BID  
12.  OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain - 
Moderate 
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every eight 
(8) hours Disp #*12 Tablet Refills:*0 
13.  Vitamin D 1000 UNIT PO DAILY  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Encounter for chemotherapy
Penile Cancer

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Dear Mr. ___,

It was our pleasure to care for you at ___.

You came to the hospital to start chemotherapy for your cancer.

WHAT HAPPENED IN THE HOSPITAL?
- you had a port placed in your chest to allow easy access for 
chemotherapy
- you started your first cycle of chemotherapy which you 
tolerated well

WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- follow up closely with oncology tomorrow ___ for an 
injection to support your blood counts

We wish you all the best!

Sincerely,
Your care team at ___
 
Followup Instructions:
___

{'pain in low back': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Unspecified asthma', 'Rheumatoid arthritis'], 'pain at surgical incision site': ['Malignant neoplasm of penis', 'unspecified'], 'no fever, chills, or night sweats': ['Encounter for antineoplastic chemotherapy', 'Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes', 'Secondary malignant neoplasm of other specified sites'], 'no nausea or vomiting': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Unspecified asthma', 'Rheumatoid arthritis'], 'no chest pain or shortness of breath': ['Encounter for antineoplastic chemotherapy', 'Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes', 'Secondary malignant neoplasm of other specified sites'], 'no difficulty breathing': ['Unspecified asthma'], 'no swelling or edema': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Rheumatoid arthritis'], 'no weakness or numbness': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Rheumatoid arthritis'], 'no changes in vision': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Rheumatoid arthritis'], 'no changes in bowel habits': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Rheumatoid arthritis'], 'no urinary symptoms': ['Essential (primary) hypertension', 'Hyperlipidemia', 'Type 2 diabetes mellitus without complications', 'Rheumatoid arthritis'], 'no other symptoms': ['Encounter for antineoplastic chemotherapy', 'Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes', 'Secondary malignant neoplasm of other specified sites']}