Malignant neoplasm of colon unspecified site Malignant neoplasm of liver secondary Secondary malignant neoplasm of retroperitoneum and peritoneum Secondary malignant neoplasm of lung Unspecified disease of pharynx Acquired absence of intestine (large) (small) Unspecified essential hypertension Do not resuscitate status
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
dyspnea
 
Major Surgical or Invasive Procedure:
Direct laryngoscopy at bedside by ENT

 
History of Present Illness:
his patient is a ___ year old male, hx of metastatic colon 
cancer, who was sent to ED from ___ clinic today. Pt was 
seen in f/u for ongoing clinical trial, is C1D28 of protocol 
___. He was reporting increased dyspnea and wheezing. It 
began 2 weeks ago and has progressively gotten worse over the 
past few days. His family has noticed increasing wheezing at 
rest and increasing cough productive of white phlegm, no 
hemoptysis. He also had ongoing weight loss, total 10lb since 
starting investigational regimen
He denies chest pain and palpitations. He has persistent right 
upper quadrant pain that has not changed since beginning 
treatment, has declined pain meds for this. Denies any cough or 
hemoptysis. Denies fever/chills. No HA or neck pain, no 
bleeding.
CXR in clinic today showed increased pulm nodules as well as 
enlargement of a lesion in the arytenoid cartilage, leading to 
extrathoracic tracheal narrowing.
He was referred to ED where CT neck showed mass inferior to 
right vocal cord with significant airway narrowing. ENT was 
consulted for emergent tracheostomy. Scope performed by ENT at 
bedside. Received decadron x 1.
Pt has declined tracheostomy. Palliative/case management was 
consulted and plan is to enroll pt in hospice, however he was 
not stable for discharge from ED until arrangements can be made.
 
Past Medical History:
ONCOLOGIC HISTORY:  He had an extended right hemicolectomy in 
___, for a T3, N0 adenocarcinoma, a rise in CEA in late 
___,
prompted a left lateral segmentectomy in ___, by Dr. ___ 
___ isolated liver metastasis.  Postoperatively, CEA normalized 
and he received six courses of FOLFOX ending in ___.  
Treatment was complicated by mild peripheral neuropathy, which 
cleared only incompletely and a progressively enlarging spleen, 
which on laparoscopic splenectomy was only remarkable for small 
focus of necrosis.  Midepigastric pain in the ___, 
which did not improve with a course of anti H. pylori treatment 
prompted a CT scan, which demonstrated a new pulmonary nodule 
and a paraaortic lymph node.  In the intervening time, he 
underwent resection of a pyogenic granuloma from the anterior 
right inferior turbinate by Dr. ___ on ___.  An 
attempted CT scan guided biopsy of the periaortic soft tissue 
mass in ___, was nondiagnostic.  His CEA remained flat and 
periodic CTs demonstrated progressively, but slowly enlarging 
masses in the retroperitoneum and lung.  A repeat biopsy in 
early ___, finely demonstrated metastatic adenocarcinoma.  
He began salvage chemotherapy with FOLFOX and Avastin in mid 
___.
.
Other Past Medical History:  
Hypertension
 
Social History:
___
Family History:
Essentially negative for any cancer except for a
father who died at age ___ of lung cancer after heavy smoking all
his life.  His mother died in her ___ of old age.  He has one
brother who is alive and well.
 
Physical Exam:
Physical Exam
General: NAD, cachectic
VITAL SIGNS: T 97.7 BP 131/82 HR 83 RR 20 94%RA
HEENT: MMM, no OP lesions
Neck: supple, no JVD, firm 5cm mass L distal trachea, 
inspiratory and exp stridor
CV: RR, NL S1S2 no S3S4 or MRG
PULM: referred high pitched upper airway sounds, nonlabored
ABD: BS+, soft, mild ttp RUQ
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, face symmetric, moves 
all ext, no clonus

 
Pertinent Results:
___ 12:30PM BLOOD WBC-6.2 RBC-3.90* Hgb-12.0* Hct-40.0 
MCV-103* MCH-30.9 MCHC-30.0* RDW-13.9 Plt ___
___ 12:30PM BLOOD Neuts-73.9* Lymphs-17.6* Monos-6.2 
Eos-1.5 Baso-0.7
___ 12:30PM BLOOD ___ PTT-35.1 ___
___ 12:30PM BLOOD Glucose-90 UreaN-9 Creat-0.8 Na-138 K-4.3 
Cl-97 HCO3-28 AnGap-17
 
Brief Hospital Course:
Mr ___ is a ___ yr old male with hx metastatic colon Ca involving 
liver, peritoneum and lung who is admitted with arytenoid 
cartilage mass with compromise of upper airway. Given his poor 
prognosis and progression despite all available treatments, he 
elected to transition to hospice this admission. 

Active Issues

# Likely Metastatic Colon Cancer: patient had increased dyspnea 
and wheezing for 2 weeks ago and has progressively gotten worse 
over the past few days. Increasing wheezing at rest and 
increasing cough productive of white phlegm, no hemoptysis. CXR 
in clinic showed increased pulm nodules as well as enlargement 
of a lesion in the arytenoid cartilage, leading to extrathoracic 
tracheal narrowing. He was referred to ED where CT neck showed 
mass inferior to right vocal cord with significant airway 
narrowing. ENT was consulted for emergent tracheostomy. Scope 
performed by ENT at bedside. Received decadron x 1. Pt has 
declined tracheostomy despite a repeated invitation. 
Palliative/case management was consulted and patient was 
enrolled in hospice prior to discharge.

Transitional Issues:
-Please follow up with oncology appointment
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea 
2. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting 
3. Verapamil SR 240 mg PO Q24H 
4. Acetaminophen 325-650 mg PO Q6H:PRN mild pain, fever 
5. LOPERamide 4 mg PO QID:PRN diarrhea 

 
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN mild pain, fever 
2. LOPERamide 4 mg PO QID:PRN diarrhea 
3. Ondansetron 8 mg PO Q8H:PRN nausea 
4. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting 
5. Verapamil SR 240 mg PO Q24H 
6. Dexamethasone 4 mg PO DAILY 
RX *dexamethasone 4 mg 1 tablet(s) by mouth daily Disp #*15 
Tablet Refills:*0
7. Racepinephrine 0.5 mL IH Q4H:PRN stridor, dyspnea 
RX *racepinephrine 2.25 % 0.5 (One half) mL INH q4h:prn Disp #*4 
Vial Refills:*0
8. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q4H:PRN 
pain/shortness of breath 
RX *morphine concentrate 20 mg/mL 0.25 ml by mouth q4h:prn Disp 
___ Milliliter Refills:*0
9. Lorazepam 1 mg PO Q6H:PRN anxiety 
RX *lorazepam 1 mg 1 tablet(s) by mouth q6h:prn Disp #*45 Tablet 
Refills:*0
10. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours 
RX *scopolamine base [Transderm-Scop] 1.5 mg/72 hour 1 ptch TD 
q72h Disp #*4 Patch Refills:*0
11. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of 
breath 
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 ml inh q4h:prn 
Disp #*15 Vial Refills:*0

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary Diagnosis:
1. Metastatic Colon Cancer

 
Discharge Condition:
Condition: stable
Mental status: alert and oriented. calm and cooperative
Ambulatory status: ambulates without assistance

 
Discharge Instructions:
Dear Mr. ___,

You were admitted for difficulty breathing and wheezing. You 
were admitted for observation and symptom management.  You 
received steroids which greatly improved your symptoms.  
Palliative care was consulted and hospice was setup on 
discharge. 

Thank you for letting us participate in your care.

Your ___ Team
 
Followup Instructions:
___

{'dyspnea': ['Malignant neoplasm of colon', 'Secondary malignant neoplasm of lung'], 'wheezing': ['Malignant neoplasm of colon', 'Secondary malignant neoplasm of lung'], 'weight loss': ['Malignant neoplasm of colon', 'Secondary malignant neoplasm of lung'], 'right upper quadrant pain': ['Malignant neoplasm of liver', 'Secondary malignant neoplasm of retroperitoneum and peritoneum'], 'mass inferior to right vocal cord': ['Unspecified disease of pharynx'], 'extrathoracic tracheal narrowing': ['Unspecified disease of pharynx'], 'increasing pulm nodules': ['Secondary malignant neoplasm of lung'], 'enlargement of a lesion in the arytenoid cartilage': ['Unspecified disease of pharynx'], 'hypertension': ['Unspecified essential hypertension']}