Encounter for antineoplastic chemotherapy Multiple myeloma not having achieved remission Hypo-osmolality and hyponatremia Pathological fracture in neoplastic disease other specified site initial encounter for fracture Family history of malignant neoplasm of other organs or systems Nausea with vomiting unspecified Adverse effect of antineoplastic and immunosuppressive drugs initial encounter Patient room in hospital as the place of occurrence of the external cause
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
tree nut / Bactrim
 
Attending: ___
 
Chief Complaint:
admit for HD Cytoxan prior to stem cell
mobilization

 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ year old male with MM s/p 4 cycles RVD now admitted for
Cytoxan stem cell mobilization. Bone marrow biopsy ___ showed 4%
of aspirate plasma cells, significant reduction compared to 
prior
(was 48% of aspirate).

States ___ previously had leg swelling on dex but none currently,
otherwise no headaches, cough, sore throat, fevers, rash, abd
pain, diarrhea, chest pain/SOB, constipation, BRBPR, melena. All
other 10 point ROS neg.

REVIEW OF SYSTEMS:
GENERAL: No fever, chills, night sweats, recent weight changes.
HEENT: No sores in the mouth, painful swallowing, intolerance to
liquids or solids, sinus tenderness, rhinorrhea, or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No cough, shortness of breath, hemoptysis, or wheezing.
GI: No nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel habits, hematochezia, or melena.
GU: No dysuria or change in bladder habits.
MSK: No arthritis, arthralgias, myalgias, or bone pain.
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness/tingling,
paresthesias, or focal neurologic symptoms.
PSYCH: No feelings of depression or anxiety. All other review of
systems negative.

 
Past Medical History:
ONC HISTORY:
Regarding his myeloma:
His presentation
is notable for a history of worsening back pain for ~1 month,
which when worked up by MRI demonstrated multiple compression
fractures and a BM signal intensity c/f myeloma. W/u revealed
leukopenia (WBC 2.4), Anemia (Hgb 8.7), Cr 1.01, Ca 8.8, Alb 
2.8,
IgG of 9190, M spike with 7.2g/dL, IgA and IgM <10 with Kappa:
Lambda ratio of >90.5, B2 Microglobulin of 6.38 BMBx on ___
demonstrated infiltrate with 80% plasma cells, c/w with a Dx of
Stage III (IgG > 7g/dl and Advanced lytic lesions) ISS Stage III
(Beta 2 >5.5mg/dL). ___ was started on RVD by Dr. ___ on
___. ___ has tolerated it fairly well and has completed 4 
cycles.

PAST MEDICAL HISTORY:
lower back pain

PAST SURGICAL HISTORY:
- Tonsillectomy; eye surgery for lazy eye
- right hand surgery

 
Social History:
___
Family History:
Siblings: Brother with soft tissue sarcoma on knee
Mother: No known history of cancer or blood disorders
Father: No known history of cancer or blood disorders; still
alive, ___ year old
Aunts: No known history of cancer or blood disorders
Uncles: No known history of cancer or blood disorders
Maternal Grandmother: No known history of cancer or blood
disorders; died of unknown type
Maternal Grandfather: No known history of cancer or blood
disorders; lived to ___
Paternal Grandmother: No known history of cancer or blood
disorders
Paternal Grandfather: No known history of cancer or blood
disorders
Children: No known history of cancer or blood disorders

 
Physical Exam:
VITAL SIGNS: 98.4  102/60  80  18  95% RA
General:  NAD
HEENT:  MMM, no OP lesions
CV:  RR, NL S1S2 no S3S4 MRG
PULM:  CTAB
GI:  BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS:  No edema, clubbing, tremors
SKIN:  No rashes or skin breakdown
NEURO: Oriented x3. Non-focal
 
Pertinent Results:
___ 08:33AM BLOOD WBC-5.2 RBC-3.96* Hgb-12.5* Hct-37.1* 
MCV-94 MCH-31.6 MCHC-33.7 RDW-14.0 RDWSD-48.8* Plt ___

___ 04:40PM BLOOD Na-141
___ 09:00PM BLOOD Na-129*
___ 05:30PM BLOOD Na-126*
___ 11:01AM BLOOD Na-127*

___ 07:38AM BLOOD Glucose-120* UreaN-17 Creat-0.6 Na-129* 
K-3.7 
___ 01:00PM BLOOD Glucose-101* UreaN-22* Creat-0.8 Na-138 
K-3.8 

___ 06:24AM BLOOD Glucose-76 UreaN-16 Creat-0.7 Na-138 
K-4.1 Cl-103 HCO3-29 AnGap-___ w/ MM s/p 4 cycles RVD admitted for Cytoxan stem cell 
mobilization c/b mod-severe hyponatremia. 

# Hyponatremia 
Na dropped from 138 to 127 within 24 hrs with associated HA but 
no MS changes. ___ was seen by nephrology. Considering the 
elevated UNa and Osms, along with clinical history of Cytoxan 
induced nausea and ongoing aggressive IVF
administration, it was thought that this was ADH induced 
hyponatremia from Cytoxan related nausea. ___ was placed on 1L PO 
fluid restriction and salt tabs and Na improved to back to 141 
within 24 hrs. His symptoms improved and ___ was monitored 
overnight without PO restrictions and NaCL tabs and his Na 
remained normal on 138. ___ will need to have his sodium 
monitored carefully if ___ will receive Cytoxan again. 

# MM 
Completed RVD, Bm BX ___ with 4% plasma cells in aspirate and 
___ in marrow, significant reduction from 48%. ___ was admitted 
for Cytoxan mobilization and completed it with the complication 
of hyponatremia and nausea. 

- ___ started cipro and zarxio, has scripts and zarxio at home
- SC collection in 10 days
- c/w zometa as outpatient
- plan for upcoming auto transplant per ___
- monitor for nausea with chemo, anti-emetics prn
- ppx: cont acyclovir, pt taking BID ___ reports

# Lower back pain
# H/o compression fractures at T5/T7 - chronic 
-  cont prn oxy/tramadol

____________________
___, D.O.
Heme/___ Hospitalist
___

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H 
2. LORazepam 0.5 mg PO Q8H:PRN nausea/insomnia/anxiety 
3. Ondansetron 8 mg PO Q8H:PRN nausea 
4. OxycoDONE (Immediate Release)  5 mg PO Q8H:PRN pain 
5. Vitamin D 1000 UNIT PO DAILY 
6. Senna 8.6 mg PO DAILY 
7. Docusate Sodium 100 mg PO DAILY 
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 

 
Discharge Medications:
1. Acyclovir 400 mg PO Q12H 
2. Docusate Sodium 100 mg PO DAILY 
3. Ciprofloxacin HCl 500 mg PO Q12H 
start ___, for 10 days 
4. LORazepam 0.5 mg PO Q8H:PRN nausea/insomnia/anxiety 
5. Ondansetron 8 mg PO Q8H:PRN nausea 
6. OxycoDONE (Immediate Release)  5 mg PO Q8H:PRN pain 
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 
8. Senna 8.6 mg PO DAILY 
9. Vitamin D 1000 UNIT PO DAILY 
10. Filgrastim 300 mcg SC Q24H 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Multiple Myeloma

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

 
Discharge Instructions:
You were admitted for high dose Cytoxan for stem cell 
mobilization. 

Please follow the instructions given to you by your nurse 
___. In brief this includes taking 
ciprofloxacin (antibiotic) and neupogen injections until you are 
told to stop.

You also had low sodium levels. This was most likely due to a 
side effect from the chemotherapy and nausea. You improved with 
time, salt tablets, and fluid restriction. You do not have to be 
on any further restrictions. 
 
Followup Instructions:
___

{'lower back pain': ['Multiple myeloma not having achieved remission', 'Pathological fracture in neoplastic disease'], 'leg swelling': [], 'headaches': [], 'cough': [], 'sore throat': [], 'fevers': [], 'rash': [], 'abd pain': [], 'diarrhea': [], 'chest pain/SOB': [], 'constipation': [], 'BRBPR': [], 'melena': [], 'no fever, chills, night sweats, recent weight changes': [], 'no sores in the mouth, painful swallowing, intolerance to liquids or solids, sinus tenderness, rhinorrhea, or congestion': [], 'no chest pain, chest pressure, exertional symptoms, or palpitations': [], 'no cough, shortness of breath, hemoptysis, or wheezing': [], 'no nausea, vomiting, diarrhea, constipation or abdominal pain': [], 'no dysuria or change in bladder habits': [], 'no arthritis, arthralgias, myalgias, or bone pain': [], 'no rashes, itching, or skin breakdown': [], 'no headache, visual changes, numbness/tingling, paresthesias, or focal neurologic symptoms': [], 'no feelings of depression or anxiety': [], 'hyponatremia': ['Encounter for antineoplastic chemotherapy', 'Hypo-osmolality and hyponatremia'], 'worsening back pain': ['Multiple myeloma not having achieved remission', 'Pathological fracture in neoplastic disease'], 'elevated UNa and Osms': [], 'clinical history of Cytoxan induced nausea': [], 'ongoing aggressive IVF administration': [], 'ADH induced hyponatremia from Cytoxan related nausea': ['Encounter for antineoplastic chemotherapy', 'Hypo-osmolality and hyponatremia'], 'nausea with vomiting': ['Nausea with vomiting'], 'adverse effect of antineoplastic and immunosuppressive drugs': ['Adverse effect of antineoplastic and immunosuppressive drugs']}