Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Secondary malignant neoplasm of lung Secondary malignant neoplasm of retroperitoneum and peritoneum Unspecified essential hypertension Enlargement of lymph nodes Personal history of malignant neoplasm of large intestine
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Leg swelling
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ y/o male with history of hypertension, metastatic colonic 
adenocarcinoma with mets to lung/RP LAD presenting with LLE 
swelling.  Patient on C2D3 of FOLFOX+Avastin.  Started noting 
yesterday progressive LLE swelling and pain with exention up 
leg.  Came into ED for evaluation.  In ED, LENIs showng 
extensive LLE clot burden.  No complaints of palpitations, chest 
pain, or shortness of breath.  No recent prolonged immobility.  
Patient started on heparin and admitted to OMED for further 
manegment.
 
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:
VS: 97.0 125/82 60 18
GENERAL: Well appearing middle aged man in NAD.
HEENT: PERLL, EOMI, OP clear without lesion.
NECK: Supple, no LAD
HEART: RRR, No MRG
LUNG: Nonlabored, CTAB
GI: Soft, NT/ND. Normoactive BS.
EXT: Notable swollen left leg from thigh to ankle with 
blue/purple discoloration. Not particularly warm or tender. No 
pitting noted.
NEURO: CNII-XII intact. No gross sensory or motor deficits. 
AAOx3.
 
Pertinent Results:
___ 06:00PM BLOOD WBC-1.8*# RBC-4.04* Hgb-13.0* Hct-37.4* 
MCV-93 MCH-32.3* MCHC-34.8 RDW-14.7 Plt ___
___ 06:37AM BLOOD WBC-2.9*# RBC-4.02* Hgb-12.8* Hct-37.3* 
MCV-93 MCH-31.8 MCHC-34.3 RDW-14.8 Plt ___
___ 06:00PM BLOOD ___ PTT-23.0 ___
___ 06:37AM BLOOD ___ PTT-150* ___
___ 06:00PM BLOOD Glucose-123* UreaN-15 Creat-0.8 Na-139 
K-4.4 Cl-102 HCO3-24 AnGap-17
___ 06:37AM BLOOD Glucose-117* UreaN-14 Creat-0.7 Na-138 
K-4.6 Cl-103 HCO3-25 AnGap-15
___ 06:37AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.5
___ 06:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-30 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:00PM URINE RBC-3* WBC-2 Bacteri-FEW Yeast-NONE 
Epi-<1
___ 06:00PM URINE CastHy-3*

IMAGING
___ US ___:
1. Extensive DVT within the left lower extremity.
2. No DVT in the right leg.

CT Head ___:
No CT evidence for intracranial metastases; MR is more sensitive
for detecting small masses.

 
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
___ year old with metastatic colon cancer undergoing salvage 
chemotherapy presents with lower extremity swelling, found to 
have DVT and no signs or symptoms of PE.

ACTIVE ISSUES
# DVT: Patient was started on heparin drip night of admission. 
Patient was switched to lovenox 60 sc bid morning after 
admission. He was discharged with instructions to continue 
therapeutic lovenox indefinitely, or until told otherwise by his 
outpatient oncologist.

# Metastatic colon cancer: On admission, patient was C2D2 of 
modified FOLFOX with bevacizumab and was still receiving ___ 
infusion. After consulting with attending, Patient was still on 
___ pump when presented to floor. Pump was due to come off day 
after admission (___) and it was ended on arrival to floor 
after discussion with attending, infusion was discontinued. 
Patient is to follow up as previously planned with his 
outpatient oncologist.

CHRONIC ISSUES

#HTN: Well controlled. Continued home lisinopril and verapamil.

OUTSTANDING STUDIES
- None

TRANSITIONAL ISSUES
- Continue lovenox for at least ___ months, or perhaps 
indefininitely based on risk/benefit evaluation.
 
Medications on Admission:
APREPITANT [EMEND] - 80 mg Capsule - One Capsule(s) by mouth 
once daily for two days after each course of chemotherapy; start 
24 hours after chemotherapy is given
DEXAMETHASONE - 4 mg Tablet - One Tablet(s) by mouth twice daily 
for 48 hours after each course of chemotherapy
LISINOPRIL -  (Prescribed by Other Provider) - 10 mg Tablet - 
Tablet(s) by mouth daily
ONDANSETRON - 8 mg Tablet, Rapid Dissolve - one Tablet(s) by 
mouth every 8 hours as needed for as needed for nausea or 
vomiting
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth 
every ___ as needed for nausea
VERAPAMIL -  (Prescribed by Other Provider) - 240 mg Tablet 
Extended Release - 1 Tablet(s) by mouth once a day
 
Discharge Medications:
1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe 
Subcutaneous twice a day.
Disp:*60 syringes* Refills:*2*
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
3. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, 
Rapid Dissolve PO every eight (8) hours as needed for nausea.  
4. verapamil 240 mg Tablet Extended Release Sig: One (1) Tablet 
Extended Release PO once a day.  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primay: Deep vein thrombosis
Secondary: Metastatic colon cancer

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

 
Discharge Instructions:
Dear Mr. ___,

You were admitted to the hospital because you noticed swelling 
in your leg. We did an ultrasound which showed a blood clot in 
the veins of that leg. We started you on blood thinning 
medication. You will need to take this medicine (2 shots a day) 
every day until your doctor tells you to stop (several months at 
the least). Please note the following changes to your 
medications:

START: Enoxaparin (Lovenox) injections 60mg twice daily

Also, please wear a compression stocking to your left leg to 
help with the swelling. It has been a pleasure taking care of 
you.
 
Followup Instructions:
___

{'Leg swelling': ['Acute venous embolism and thrombosis of deep vessels of proximal lower extremity'], 'Pain with extension up leg': ['Acute venous embolism and thrombosis of deep vessels of proximal lower extremity'], 'No complaints of palpitations, chest pain, or shortness of breath': [], 'No recent prolonged immobility': [], 'Extensive LLE clot burden': ['Acute venous embolism and thrombosis of deep vessels of proximal lower extremity'], 'Metastatic colonic adenocarcinoma': ['Secondary malignant neoplasm of lung', 'Secondary malignant neoplasm of retroperitoneum and peritoneum'], 'Hypertension': ['Unspecified essential hypertension'], 'Enlarging spleen': [], 'Midepigastric pain': [], 'Pyogenic granuloma': [], 'Peripheral neuropathy': [], 'Spleen necrosis': [], 'Pulmonary nodule': ['Secondary malignant neoplasm of lung'], 'Paraaortic lymph node': ['Secondary malignant neoplasm of retroperitoneum and peritoneum'], 'CEA remained flat': [], 'Progressively enlarging masses in retroperitoneum and lung': ['Secondary malignant neoplasm of retroperitoneum and peritoneum', 'Secondary malignant neoplasm of lung']}