Secondary malignant neoplasm of lung Pneumonia organism unspecified Secondary malignant neoplasm of mediastinum Secondary malignant neoplasm of bone and bone marrow Malignant neoplasm of other specified sites of pancreas Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Diabetes with neurological manifestations type II or unspecified type uncontrolled Polyneuropathy in diabetes Unspecified essential hypertension Constipation unspecified Coronary atherosclerosis of unspecified type of vessel native or graft Aortocoronary bypass status
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
Cough.
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ yo man with known (new) metastatic pancreatic cancer with 
cough, hemoptysis, dyspnea. These symptoms have been present for 
the past ___ months but seem gradually worse, now productive of 
yellow phlegm and occasional blood tinge to sputum. No fevers or 
chills, recently started on atrovent with some releif. He notes 
also constipation x last few days. Of note he lives in ___ 
and ___ been down there until ___, came here to live with son. 
Noted anterior chest wall mass and associated pain in neck and 
shoulders, biopsy last week showed met panc ca. He notes wt loss 
of 10 lbs, ? poor po intake. Pain across low abdomen 'pressure 
like' ___. No dysuria but nocturia. No CP. He notes his mental 
status is 'a little off' and son feels this is deteroirating 
recently as well. He also notes some episodes of hypoglycemia 
due to poor po intake.

In the ED: VS: 98.5 64 110/50 16 99% on RA. He was given 
levofloxacin.

ROS: 10 point review of systems negative except as noted above.
 
Past Medical History:
CAD, s/p CABG
pancreatic ca
DM, type II with neuropathy
hypertension
bph
 
Social History:
___
Family History:
Father with ? sudden cardiac death.
 
Physical Exam:
VS: T 97.2 HR 63 BP 140/58 RR 20 Sat 100% RA
Gen: Elderly man in NAD
Eye: extra-occular movements intact, pupils equal round, 
reactive to light, sclera anicteric, not injected, no exudates, 
mild proptosis bilaterally
ENT: mucus membranes dry, no ulcerations or exudates
Neck: no thyromegally, JVD: flat, anterior neck mass palpable
Cardiovascular: regular rate and rhythm, normal s1, s2, no 
murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes, 
rales or rhonchi
Abd: Soft, mildly tender to palpation over bilateral lower 
quadrants, slightly distended ? fluid wave, bowel sounds present
Extremities: 3+ PE to knees bilaterally, no cyanosis, clubbing, 
joint swelling
Neurological: Alert and oriented x3 but very tangential in 
speech, CN II-XII intact, normal attention
Integument: Warm, moist, no rash or ulceration  
Psychiatric: appropriate, pleasant, slightly anxious
 
Pertinent Results:
Admit labs:
cbc: WBC-22.3* RBC-4.20* HGB-11.8* HCT-36.7* MCV-88 MCH-28.2 
MCHC-32.3 RDW-15.7* PLT COUNT-419 NEUTS-89.2* LYMPHS-5.5* 
MONOS-4.2 EOS-0.8 BASOS-0.2
BMP:  GLUCOSE-42* UREA N-12 CREAT-0.5 SODIUM-133 POTASSIUM-4.3 
CHLORIDE-97 TOTAL CO2-28
AMMONIA-39
LACTATE-2.2*
cTropnT-<0.01
___ 07:10AM BLOOD CEA-288*
___ PTT-28.1 ___
UA: BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG 
BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG ___ 
BACTERIA-OCC YEAST-NONE EPI-0

CTA ___ wet read: 1. no PE or acute aortic syndrome
2. pulmonary mets w/ new foci of opacity - may represent 
additional mets vs
infection
3. worsening bony mets and mediastinal lymphadenopathy  

CT ABDOMEN
Preliminary Report !! WET READ !!
1) Pancreatic tail mass measuring up to 6.1 x 5.1 cm, cannot be 
clearly
separated from left adrenal gland.
2) Multiple liver hypodensities consistent with metastatic 
disease.
3) Lymphadenopathy, notably periportal and peripancreatic.
4) Pulmonary lesions and right pleural effusion better evaluated 
on chest CT
___, similar in appearance.
5) Non-visualized splenic vein with significant collateral 
formation,
indicative of chronic occlusion.
6) Ascites.
7) Previously seen lytic lesion in L1 vertebral body, new from 
___.
8) Splenic calcifications, likely sequelae of prior 
granulomatous disease.

 
Brief Hospital Course:
___ yo man with met panc ca, dyspnea.

1. Dyspnea: suspect secondary to mets rather than infection 
given duration of symptoms, however, given ct findings, ___ 
empiric trial of abx may be reasonable. Initiated nebs and 
levofloxacin given. Patient symptomatically improved and 
remained afebrile.

2. Leukocytosis: no clear infection, possible pulmonary source, 
thought likely ___ malignancy

3. Pancreatic ca: metastatic, 
Oncology service was consulted for discussion of treatment 
options. They discussed with patient and his son the option of 
chemotherapy as well as the likely need for palliative radiation 
to the sterum given the high likelihood that this will cause 
worsening s

4. CAD, bypass graft: cont. aspirin, statin, bb, acei

5. DM, type II, uncontrolled: decrease lantus to avoid 
hypoglycemia, ssi

6. BPH: cont. tamsulosin

7. Neuropathy: cont. lyrica. 

8. Constipation: miralax, colace, monitor.

Full code.

ppx: heparin

HCP: son, ___ ___
 
___ on Admission:
vitamin c 500mg bid
aspirin 81mg daily
glyburide 5mg bid
metformin 500mg bid
humalog 8 units with meals
lantus 60 units qhs
lipitor 10mg daily
lisinopril 2.5mg daily
lyrica 50mg daily
multivitamin daily
tamsulosin 0.4mg daily
toprol xl 100mg daily
atrovent 2 puffs qid
 
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY 
(Daily) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
2. Ascorbic Acid ___ mg Tablet Sig: One (1) Tablet PO BID (2 
times a day).  
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).  
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
5. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO DAILY 
(Daily).  
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) 
Capsule, Sust. Release 24 hr PO HS (at bedtime).  
7. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: 
Two (2) Puff Inhalation QID (4 times a day).  
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr 
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).  
9. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).  
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
12. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
13. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.  
14. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.  

15. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day as 
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
16. Oxycodone 10 mg Tablet Sig: One (1) Tablet PO every four (4) 
hours as needed for pain: This medication may make you drowsy. 
You should not drive while taking this medication.
Disp:*60 Tablet(s)* Refills:*1*
17. Chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO BID (2 
times a day) as needed for hiccups.
Disp:*30 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
1) Metastatic pancreatic cancer
2) Possible pneumonia

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

 
Discharge Instructions:
You were admitted with dyspnea. You were found to have a 
possible pneumonia.  

You were prescribed several new medications, including:
1) Levofloxacin
2) Oxycodone for breakthrough pain
3) Senna to prevent constipation
4) Colace to prevent constipation
5) Thorazine for hiccups

Please take these as prescribed
 
Followup Instructions:
___

{'cough': ['Secondary malignant neoplasm of lung', 'Pneumonia, organism unspecified'], 'hemoptysis': ['Secondary malignant neoplasm of lung'], 'dyspnea': ['Secondary malignant neoplasm of lung', 'Pneumonia, organism unspecified'], 'constipation': ['Constipation, unspecified'], 'weight loss': ['Malignant neoplasm of other specified sites of pancreas'], 'anterior chest wall mass': ['Secondary malignant neoplasm of mediastinum'], 'pain in neck and shoulders': ['Secondary malignant neoplasm of bone and bone marrow'], 'mental status changes': [], 'hypoglycemia': ['Diabetes with neurological manifestations, type II or unspecified type, uncontrolled'], 'nocturia': [], 'pressure like sensation in low abdomen': []}