Encounter for antineoplastic chemotherapy Other myeloid leukemia not having achieved remission Fatty (change of) liver not elsewhere classified Gastro-esophageal reflux disease without esophagitis Gastritis unspecified without bleeding
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
HiDAC
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
Mr. ___ is a ___ male with history AML s/p 
7+3 induction now s/p 3C of HiDAC. Developed FN after C2 of 
HiDAC with no obvious infectious source found now presenting for 
C4 of HiDAC.
 
Past Medical History:
Past Medical History:

Patient presented to ___ with a 3 week history of 
weakness on ___. ___ revealed leukocytosis with blasts for 

which he was transferred to ___. Bone marrow biopsy confirmed 
acute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement. 
Patient was started on 7+3 on ___. Day 14 bone marrow with 

aplasia but persistent t(8;21) in 40% of cells per karyotype and 

RUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made 
not to re-induce. Day 21 bone marrow on ___ was with no 
morphologic or cytogenetic evidence of residual disease.

Treatment History:
- ___: 7+3
- ___: BMB with ___
- ___: C1D1 HiDAC
- ___: C2D1 HiDAC
- ___: C3D1 HiDAC
 
Social History:
___
Family History:
Both mother and father died of old age. He denies any family 
history of malignancy or blood disorders.
 
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Temp 97.9 BP 130/70 HR 72 RR 16 O2 sat 98% RA.
___: NAD.
HEENT: MMM, no OP lesions, no cervical, supraclavicular, 
axillary
adenopathy, no thyromegaly.
CV: RR, NL S1S2 no S3S4 MRG.
PULM: CTAB.
GI: BS+, soft, slight pain on palpation of epigastric region. no
masses or hepatosplenomegaly.
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy.
SKIN: No rashes or skin breakdown port site intact w/o erythema.
Pt does have darker brown skin lesions over anterior foreleg on
left but states chronic.
NEURO: A&Ox3. Cranial nerves II-XII are within normal limits.
Gross strength and sensation intact. no nystagmus, rapid hand
movements and tandem gait intact.

DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: 97.8 PO ___ 20 98 RA 
___: NAD.
HEENT: MMM.
CV: RR, NL S1S2 no S3S4 MRG.
PULM: CTAB.
ABD: soft/nt/nd, no HSM
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy.
SKIN: No new rashes
NEURO: A&Ox3. Cranial nerves II-XII are within normal limits.
Gross strength and sensation intact. no nystagmus, rapid hand
movements and tandem gait intact.  FNF intacdt and negative 
romberg
 
Pertinent Results:
ADMISSION LABS:

___ 09:05AM BLOOD WBC-4.4 RBC-3.23* Hgb-10.8* Hct-32.4* 
MCV-100* MCH-33.4* MCHC-33.3 RDW-20.2* RDWSD-72.9* Plt ___
___ 09:05AM BLOOD Neuts-50.8 ___ Monos-17.3* 
Eos-0.5* Baso-0.7 Im ___ AbsNeut-2.23 AbsLymp-1.34 
AbsMono-0.76 AbsEos-0.02* AbsBaso-0.03
___ 09:05AM BLOOD Glucose-112*
___ 09:05AM BLOOD UreaN-12 Creat-0.7 Na-139 K-4.2 Cl-102 
HCO3-25 AnGap-16
___ 09:05AM BLOOD ALT-117* AST-64* AlkPhos-83 TotBili-0.4
___ 09:05AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.1

DISCHARGE LABS:

___ 12:00AM BLOOD WBC-3.8* RBC-3.11* Hgb-10.4* Hct-31.0* 
MCV-100* MCH-33.4* MCHC-33.5 RDW-18.5* RDWSD-67.1* Plt ___
___ 12:00AM BLOOD Neuts-97.0* Lymphs-1.9* Monos-0.5* 
Eos-0.0* Baso-0.3 Im ___ AbsNeut-3.67 AbsLymp-0.07* 
AbsMono-0.02* AbsEos-0.00* AbsBaso-0.01
___ 12:00AM BLOOD Glucose-133* UreaN-15 Creat-0.6 Na-136 
K-4.2 Cl-102 HCO3-23 AnGap-15
___ 12:00AM BLOOD ALT-104* AST-56* LD(LDH)-172 AlkPhos-65 
TotBili-0.8
 
Brief Hospital Course:
Mr. ___ is a ___ male with history AML s/p 
7+3 and C3 HiDAC consolidation presenting for C4

C4D6 ___

# AML: Favorable genetics given t(8.21) s/p 7+3 and now s/p C3
HiDAC consolidation. Bone marrow biopsy, FISH, and cytogenetics
on day 21 of 7+3 indicate complete response.  He received 
Cytarabine 5940 mg IV Q12H on Days 1, 3 and 5. ___, 
___ and ___ mg/m2).  Neuro checks prior to each 
chemotherapy were performed and did nto show signs of cerebellar 
toxicity. He also received the following:
- antiemetics/IVF per protocol
- Continue acyclovir, fluc and cipro while neutropenic
- neulasta to be given  ___
- f/u set for clinic ___

#epigastric pain: mild in nature and minimal on exam, likely 
GERD/gastritis related. had w/u inhouse last admission, lipase 
WNL, afebrile. Improved with protonix, simethicone.

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H 
2. Montelukast 10 mg PO DAILY 
3. Pantoprazole 40 mg PO Q24H 
4. Simethicone 40-80 mg PO QID:PRN gas pains 
5. Ciprofloxacin HCl 500 mg PO Q12H 
6. Fluconazole 400 mg PO Q24H 

 
Discharge Medications:
1.  PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID  
2.  Acyclovir 400 mg PO Q12H 
RX *acyclovir 400 mg 1 tablet(s) by mouth q 12 hours Disp #*28 
Tablet Refills:*0 
3.  Montelukast 10 mg PO DAILY  
4.  Pantoprazole 40 mg PO Q24H 
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 
Tablet Refills:*0 
5.  Simethicone 40-80 mg PO QID:PRN gas pains  
6. HELD- Ciprofloxacin HCl 500 mg PO Q12H  This medication was 
held. Do not restart Ciprofloxacin HCl until outpatient team 
tells you to restart
7. HELD- Fluconazole 400 mg PO Q24H  This medication was held. 
Do not restart Fluconazole until outpatient team tells you to 
restart

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
AML

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

 
Discharge Instructions:
Mr. ___,

You were admitted to receive HiDAC chemotherapy. You tolerated 
this well and will be discharged home. You will follow up in 
clinic as stated below. Please do not hesitate to call in the 
meantime with any questions or concerns. It was a pleasure 
taking care of you.
 
Followup Instructions:
___

{'weakness': ['Other myeloid leukemia not having achieved remission'], 'leukocytosis with blasts': ['Other myeloid leukemia not having achieved remission'], 'acute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement': ['Other myeloid leukemia not having achieved remission'], 'fever': ['Encounter for antineoplastic chemotherapy'], 'neutropenia': ['Encounter for antineoplastic chemotherapy'], 'epigastric pain': ['Gastro-esophageal reflux disease without esophagitis', 'Gastritis'], 'darker brown skin lesions': []}