Malignant neoplasm of head of pancreas Secondary malignant neoplasm of liver and intrahepatic bile duct Dehydration Sensorineural hearing loss bilateral Gastro-esophageal reflux disease without esophagitis Essential (primary) hypertension Essential (hemorrhagic) thrombocythemia Elevated white blood cell count unspecified Hypovolemia Nausea with vomiting unspecified Do not resuscitate Neoplasm related pain (acute) (chronic) Family history of malignant neoplasm of digestive organs Abnormal weight loss Body mass index [BMI] 21.0-21.9 adult
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
latex
 
Attending: ___.
 
Chief Complaint:
Nausea, anorexia, abdominal pain
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ PMH of Deafness (uses ASL), GERD, HTN, Metastatic Pancreatic
Cancer (mets to liver, recently on palliative gemcitabine), CBD
obstruction (s/p sphincerotomy and metal stent placement) who
recently was admitted for pain control and possible pancreatitis
(s/p celiac plexus block and increased pain regimen), now 
returns
with nausea, vomiting, abdominal pain and decreased PO intake

Pt was last discharged on ___ after being admitted for possible
pancreatitis vs pain ___ progression of malignancy. She had
celiac nerve plexus block and had oxycontin initiated. As a
result pain was improved and patient was discharged with
outpatient oncology followup

OF note, patient is deaf and uses ASL to communicate for complex
decision making, but was able to communicate by writing and with
lip reading for purposes of this interview. Pt noted that since
discharge she has had intermittent abdominal pain which is
epigastric and radiating to the back, which comes on in spasms,
with sharp stabbing sensation. She noted that her pain may be 
slightly improved compared to prior though. However, she is more
concerned with nausea/vomiting at home with yellow colored
vomitus and lack of po intake ___ decreased appetite. Denied
fever, chills, sore throat, dysuria, rash, significant diarrhea. 


In the ED, initial vitals: 98.1 107 122/87 18 99% RA. Labs
revealed WBC of 23 (recent baseline was 12), Hgb 11.9 (baseline
9.5), plt 585 (baseline 268). Chem wnl, LFTs unchanged since 
last
admission. Lipase 123 down from 500 on last admit. Lactate
normal. She was given IVF, Zofran, and dilaudid. She noted that
she felt unsafe going home as did not feel remarkably improved 
so
was admitted to oncology for further care. 
 
REVIEW OF SYSTEMS:  
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI. 

 
Past Medical History:
PAST ONCOLOGIC HISTORY:  
As per OMR
"presented in ___ to
___ with painless jaundice.  At the time, 
she
also noted several weeks of nausea, vomiting, postprandial
abdominal pain and a 20-pound weight loss.  She was referred to
___ where she underwent ERCP.  This study identified a
stricture in the common bile duct due to external compression. 
Brushings were atypical.  Her CA ___ was elevated at 180 U/mL. 
She underwent endoscopic ultrasound ___, which identified a 1.8 x 1.6 cm pancreatic head mass
without vascular involvement.  Biopsy by ___ showed
adenocarcinoma.  CT angiogram also showed a 1.6 x 1.4 x 1.4 cm
pancreatic head mass with stranding but no definite involvement
at the ___ and ___.  There was no evidence of distant 
metastases.
Ms. ___ was diagnosed with borderline resectable PDA and
initiated chemotherapy with neoadjuvant FOLFIRINOX ___.
C1D15 was dose reduced for N/V/D. She was hospitalized
___ with diarrhea, nausea, anorexia, and
neutropenia.  Her C2D15 treatment was held. With cycle 3 she
transitioned to mFOLFOX.  She completed five infusion and was
taken to the OR ___.  Liver metastases were identified
intraoperatively, and plans for resection were aborted.  She
initiated palliative chemotherapy with gemcitabine ___. 
The dose was reduced to 750mg/m2 on C1D8 due to neutropenia. 
With cycle 2 she transitioned to day 1 and 15 schedule. 
Following six cycles there was further progression, and she was
referred for combination gemcitabine/nab-paclitaxel"
 
PAST MEDICAL HISTORY:  
1.  Hypertension.
2.  Congenital deafness.
3.  GERD.
4.  Goiter.
5.  History of nephrolithiasis.
6.  Hypercholesterolemia.
7.  Status post C-section x 2.
8. CBD obstruction s/p sphincerotomy and metal stent placement
via ERCP

 
Social History:
___
Family History:
The patient's father died of an MI at ___ years.
Her mother died with type 2 diabetes mellitus. A sister died 
with
colon cancer at ___ years. Another sister died of ___
disease. She has two sons without health concerns.
 
Physical Exam:
Vitals:  98.3 134/84 104 18 98RA
___: Sitting in bed, appears comfortable, no acute distress
EYES:  PERRLA
HEENT: Moist mucous membranes, oropharynx clear
NECK: Supple
LUNGS: Clear to auscultation bilaterally no wheezes rales or
rhonchi, normal respiratory rate
CV: Regular rate and rhythm without any murmurs rubs or gallops
ABD: Slight epigastric tenderness to moderate palpation,
nondistended, normoactive bowel sounds, no ascites
EXT: Normal bulk/tone, no deformity
SKIN: Warm/dry, no rash
NEURO: Alert and oriented ×3, fluent speech but has difficulty
with correct pronunciation as is deaf, but reads lips and writes
to communicate
ACCESS: chest port with dressing c/d/i
 
Pertinent Results:
___ 02:10PM   WBC-23.0*# RBC-4.30# HGB-11.9 HCT-37.1 MCV-86 
MCH-27.7 MCHC-32.1 RDW-16.1* RDWSD-48.4*
___ 02:10PM   PLT COUNT-585*#
___ 02:10PM   cTropnT-0.05*
___ 02:10PM   ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-153* TOT 
BILI-0.5
___ 02:10PM   LIPASE-123*
___ 02:10PM   GLUCOSE-132* UREA N-10 CREAT-0.4 SODIUM-138 
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-18*
___ 02:53PM   LACTATE-1.7
 
Brief Hospital Course:
Ms ___ is a pleasant ___ year-old female with deafness 
admitted with recurrent abdominal pain, nausea, and poor 
appetite attributed to her pancreatic cancer. Her anti-nausea 
and pain medications were adjusted to achieve better symptom 
control, including increase of her oxycontin dose from bid to 
tid, and adding baclofen to address some element of back spasm.  
Her appetite remained minimal, but she was able to tolerate 
fluids throughout her stay.  She met with Dr ___ our 
___ Care service and discussed options for home hospice, 
though at the time of discharge she remains uncertain whether 
she may pursue palliative chemotherapy instead.  Her ___ agency 
has the ability to deliver hospice care and will continue to 
offer information on this option after she arrives home.  
Throughout her admission she was seen at least daily with the 
assistance of our ASL interpreter.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 
2. Ondansetron ODT ___ mg PO Q8H:PRN nausea 
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 

4. Omeprazole 20 mg PO DAILY 
5. Lidocaine 5% Patch ___ PTCH TD QAM to LUQ area  
6. Milk of Magnesia 30 mL PO Q6H:PRN constipation 
7. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 
8. Polyethylene Glycol 17 g PO DAILY constipation 
9. Senna 17.2 mg PO BID constipation 
10. OLANZapine 5 mg PO BID:PRN nausea 
11. Magnesium Citrate 300 mL PO ONCE 
12. Multivitamins W/minerals 1 TAB PO DAILY 

 
Discharge Medications:
1.  Baclofen 5 mg PO Q8H:PRN Back Pain 
RX *baclofen 10 mg 0.5 (One half) tablet(s) by mouth every eight 
(8) hours Disp #*90 Tablet Refills:*2 
2.  lidocaine 5 % topical QAM 
RX *lidocaine [Lidoderm] 5 % apply to left upper abdomen qam 
Disp #*30 Patch Refills:*3
RX *lidocaine 5 % apply to left upper abdomen qam Disp #*30 
Patch Refills:*2 
3.  OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - 
Moderate 
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours 
Disp #*60 Tablet Refills:*0 
4.  OxyCODONE SR (OxyconTIN) 10 mg PO Q8H abdominal pain  
5.  Lidocaine 5% Patch ___ PTCH TD QAM to LUQ area   
6.  Magnesium Citrate 300 mL PO ONCE  
7.  Milk of Magnesia 30 mL PO Q6H:PRN constipation  
8.  Multivitamins W/minerals 1 TAB PO DAILY  
9.  OLANZapine 5 mg PO BID:PRN nausea  
10.  Omeprazole 20 mg PO DAILY  
11.  Ondansetron ODT ___ mg PO Q8H:PRN nausea  
12.  Polyethylene Glycol 17 g PO DAILY constipation  
13.  Senna 17.2 mg PO BID constipation  

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
___ Diagnosis:
Metastatic pancreatic cancer

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 
Discharge Instructions:
Please take your medications as prescribed.
 
Followup Instructions:
___

{'Nausea': ['Malignant neoplasm of head of pancreas', 'Secondary malignant neoplasm of liver and intrahepatic bile duct'], 'Anorexia': ['Malignant neoplasm of head of pancreas', 'Secondary malignant neoplasm of liver and intrahepatic bile duct'], 'Abdominal pain': ['Malignant neoplasm of head of pancreas', 'Secondary malignant neoplasm of liver and intrahepatic bile duct'], 'Vomiting': ['Malignant neoplasm of head of pancreas', 'Secondary malignant neoplasm of liver and intrahepatic bile duct'], 'Weight loss': ['Abnormal weight loss'], 'Deafness': ['Sensorineural hearing loss', 'bilateral'], 'GERD': ['Gastro-esophageal reflux disease without esophagitis'], 'Hypertension': ['Essential (primary) hypertension'], 'Thrombocythemia': ['Essential (hemorrhagic) thrombocythemia'], 'Leukocytosis': ['Elevated white blood cell count', 'unspecified'], 'Hypovolemia': ['Hypovolemia'], 'Pain': ['Neoplasm related pain (acute) (chronic)'], 'Family history': ['Family history of malignant neoplasm of digestive organs'], 'BMI': ['Body mass index [BMI] 21.0-21.9', 'adult']}