Other and unspecified infection due to central venous catheter Leukemic reticuloendotheliosis unspecified site extranodal and solid organ sites Phlebitis and thrombophlebitis of superficial veins of upper extremities Other chest pain Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled
 
Name:  ___.             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Morphine
 
Attending: ___
 
Chief Complaint:
Right arm tenderness
 
Major Surgical or Invasive Procedure:
None 

 
History of Present Illness:
The patient is a ___ woman who was diagnosed with hairy 
cell leukemia in late ___ after presenting with 
hepatosplenomegaly and thrombocytopenia to the emergency room. 
She had follow up with hematology/oncology and Dr. ___ 
diagnosis was confirmed. She underwent placement of a ___ line 
on ___ for initiation of continuous infusion cladribine at 
0.7mg/kg weekly. Early the day prior to this admission she woke 
up with pain at the ___ entry site in her right arm. She had 
been lying on her right side while sleeping. Over the course of 
the day, the pain continued and was worse with movement of the 
arm. It radiated to the right hand and was accompanied by 
numbness and tingling of her fingertips. She felt that the arm 
was slightly more swollen than her left arm, and she sought 
evaluation in the Emergency Department.  
In the ED, a right upper extremity ultrasound revealed no DVT. 
While in the ED, she developed sharp, pressure-like, "tight" 
chest discomfort, substernal, non-radiating, not accompanied by 
nausea, vomiting, and diaphoresis. She does report mild dyspnea 
which she attributes to anxiety. EKG was performed and revealed 
no evidence of ischemia; in addition, a CT scan of the chest 
showed no pulmonary embolus. She was given Percocet for her 
pain, with resolution of her discomfort. She estimates that the 
pain lasted approximately an hour before stopping.  
.
 
Past Medical History:
- Hairy cell leukemia (now status post 1 cycle Cladribine)  
- History of diabetes mellitus, untreated /diet controlled .  
- S/p knee and ankle surgeries x ___  
- S/p appendectomy  

 
Social History:
___
Family History:
Her mother is ___ and has thyroid disease and elevated 
cholesterol. Her father is ___ and has coronary artery disease 
and hemochromatosis. Her brother is ___ and well. She has one 
paternal uncle who died in his ___ from an asbestos-related 
cancer. No other family members have cancers or blood disorders. 
 

 
Physical Exam:
VITAL SIGNS: 98.2, 88, 125/87, 20, 98%RA  
ECOG performance status 0. Pain ___.  
GENERAL APPEARANCE: The patient is a pleasant woman,  
well-appearing.  
HEENT: Pupils are equal, round, and reactive to light.  
Extraocular muscles are intact. The oropharynx is clear without  

lesions. Mucous membranes are moist.  
NECK: Supple, without lymphadenopathy.  
LUNGS: Clear bilaterally without crackles or wheezes.  
HEART: S1, S2, regular without murmurs.  
ABDOMEN: Soft, nontender, nondistended. There is marked 
hepatosplenomegaly.  
EXTREMITIES: The right upper extremity is mildly tender to 
palpation slightly proximal to the PICC insertion site. There is 
no erythema or edema. Distal pulses and sensory function are 
intact.  
SKIN: No bleeding, bruising, or rash.  
NEUROLOGIC: Alert and oriented x3. CN ___ intact. Strength ___ 
in proximal and distal muscle groups, upper and lower 
extremities. Sensation intact to light touch. Cerebellar 
function intact to finger nose finger testing.  

 
Pertinent Results:
ADMISSION LABS:
___ 10:40PM   GLUCOSE-101 UREA N-15 CREAT-0.6 SODIUM-138 
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
___ 10:40PM   ALT(SGPT)-37 AST(SGOT)-33 LD(LDH)-255* 
CK(CPK)-45 ALK PHOS-55 TOT BILI-1.0
___ 10:40PM   ALBUMIN-4.2 CALCIUM-9.3 PHOSPHATE-4.3 
MAGNESIUM-1.9
___ 10:40PM   WBC-4.9 RBC-4.19* HGB-13.4 HCT-37.5 MCV-90 
MCH-32.1* MCHC-35.9* RDW-14.7, PLTs 116
___ 10:40PM   NEUTS-76.3* LYMPHS-17.7* MONOS-1.7* EOS-3.9 
.
CARDIAC ENZYMES: 
___ 10:40PM   CK-MB-NotDone cTropnT-<0.01
.
ADDITIONAL IMAGING: 

___ CTA: IMPRESSION: 
1. No pulmonary embolism. 
2. Massive splenomegaly, partially imaged. 
.
___ RIGHT UE ULTRASOUND:
IMPRESSION: No evidence of DVT.
.
CARDIAC/EKGs:
___ EKG: Rate 78-80, NSR, normal intervals, normal axis, no 
ST changes to suggest ishcemia. 
.
.
URINE STUDIES:
___ 07:40AM URINE  COLOR-Yellow APPEAR-Cloudy SP ___
___ 07:40AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 
LEUK-NEG
.
MICROBIOLOGY:
___ 9:32 am CATHETER TIP-IV// Source: ___. 
**FINAL REPORT ___
WOUND CULTURE (Final ___:  No significant growth. 
.

DISCHARGE LABS:
___ 09:00AM BLOOD WBC-1.6* RBC-4.00* Hgb-13.0 Hct-36.4 
MCV-91 MCH-32.5* MCHC-35.8* RDW-13.9 Plt ___
___ 09:00AM BLOOD Neuts-85.6* Lymphs-8.8* Monos-0.5* 
Eos-4.7* Baso-0.3
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD Glucose-151* UreaN-12 Creat-0.6 Na-137 
K-3.6 Cl-102 HCO3-25 AnGap-14
___ 09:00AM BLOOD ALT-42* AST-37 LD(LDH)-251* AlkPhos-49 
TotBili-2.2*
___ 09:00AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.8 UricAcd-4.7
 
Brief Hospital Course:
In summary, the patient is a ___ female with recent 
diagnosis of hairy cell leukemia in ___, who presented 
to ED towards the end of her Cladribine infusion cycle 
complaining of right arm pain at ___ insertion site.  
.  
# Right arm pain. The patient's presentation on physical exam 
was consistent with a superficial thrombophlebitis vs. early 
infection at ___ site. She had no fevers and no apparent 
discharge at site. Blood cultures were negative. Ultrasound of 
right upper extremity showed no abscesses and no evidence of any 
DVTs. The right PICC line was removed and a peripheral IV was 
placed in order to continue her scheduled continuous infusion of 
Cladribine therapy for her HCL. She was given some local warm 
packs, and percocet and then Tylenol for pain relief which she 
tolerated well. She had marked improvement by hospital day 2 
with less erythema, less tenderness and less edema at her prior 
right arm ___ site. Given negative screen for infectious causes 
and unremarkable ultrasound she was daignosed with a phlebitis 
reaction at ___ site that can be a common side effect of 
Cladribine. Because she only had about ~50 hours of her therapy 
left she remained inpatient for ongoing monitoring for an extra 
day until completing her full scheduled dose (25 mg remaining). 
At time of discharge she had stable vital signs, and older ___ 
site had only a small, well-healing bruise, otherwise much 
improved from initial presentation. Erythema and tenderness had 
resolved.   
.
# Hairy Cell Leukemia: Patient initially presented to ED several 
weeks ago at the beginning of ___ with chief complaint of 
abdominal pain at left upper quadrant and noted to have massive 
splenomegaly on CT. She also had thrombocytopenia so she was 
referred for hematology/oncology follow-up, and she is now being 
followed closely by Dr. ___. On this admission she was 
finishing up her planned Cladribine therapy. During her hospital 
stay she tolerated infusion very well with some occasional 
nausea which was treated with compazine initially and then some 
additional Zofran with good effects. No associated emesis, 
diarrhea or abdominal pains. On physical exam, enlarged spleen 
that was mildly tender to palpation. . She was set-up for a 
follow-up outpatient oncology appointment for about 1 week after 
her discharge. She was discharged with instructions to begin her 
prophylactic doses of Acyclovir and Bactrim DS.  Of note, she 
was already vaccinated on ___ for pneumococcus, 
meningococcus,and hemophilus influenza. 
.  
#)Chest pain: Ms. ___ complained of some vague chest 
tightness upon arrival to the ED. The cause of the patient's 
chest pain was unclear per ED staff. Cardiac enzymes were 
negative and EKG showed no ischemic changes, normal axis and 
noraml rate and intervals. Symptoms were ___ severity and 
highly atypical for acute coronary syndrome. CTA scan results 
ruled her out for any pulmonary embolus. By the time she arrived 
on ___ floor she was asymptomatic and had no further complaints 
throughout her stay. Per patient, she endorsed that she felt her 
chest pains may have been stress and anxiety related as she had 
felt very concerned about a possible line infection upon arrival 
to ED. Will continue to monitor symptoms without further 
intervention at this time.  
.  
#)Prophylaxis: The patient was not given any additional 
antocoagulation given her thrombocytopenia history. She was 
encouraged to ambulation BID-TID.   
.  
#)Code Status: The patient was maintained as a full code status 
for the entirety of her hospital course.   
.
 
Medications on Admission:
Percocet prn  
Lorazepam 0.5mg tid prn  

 
Discharge Medications:
1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a 
day.  
2. Ativan 0.5 mg Tablet Sig: ___ Tablets PO every six (6) hours 
as needed for sleep,anxiety, nausea.  
3. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) 
hours as needed for nausea.  
4. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO 3X WEEK: 
PLEASE TAKE ONE TABLET EVERY ___. .  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary: 
-Superficial Thrombophlebitis of right forearm
-Hairy Cell Leukemia
.
Secondary:
- History of diabetes mellitus, diet controlled   
- Anxiety
.
Other past medical history:
- status post knee and ankle surgeries x 3  
- status post appendectomy  

 
Discharge Condition:
Good. At time of discharge the patient had stable vital signs 
and she was in no apparent distress. 

 
Discharge Instructions:
It was a pleasure taking care of you here at ___ 
___. 
.
You were admitted with redness, irritation, local tenderness and 
swelling at the ___ IV line site in your right arm. An 
ultrasound was done to ensure you did not have any blood clots 
or abscesses. The PICC line was removed and the area seemed to 
recover well over a period of 2 days. Because you only had 2 
days left for the rest of your cladribine infusion the ___ team 
decided to monitor your right arm and continue the rest of your 
therapy as an inpatient through a new peripheral IV line. After 
you completed your therapy this line was removed. Ultimately, it 
was felt that you did not have a skin infection and you were 
diagnosed with a condition called thrombophlebitis which is a 
local irritation of the blood vessels. This is a common side 
effect of cladribine therapy. 
.
You were set up for a follow-up appointment with your primary 
oncologist as outlined below. 
.
Lastly, please return to the emergency room or call your doctor 
if you develop any new rashes, swelling of your arm, fevers, 
chills, bleeding or discharge at the infusion site, worsening 
abdominal pains, or any other concerning symptoms. 
.
MEDICATION INSTRUCTIONS:

Please start your new Bactrim and Acyclovir medications as 
instruced by your primary oncologist. Otherwise, continue your 
usual home medications. 

 
Followup Instructions:
___

{'Right arm tenderness': ['Phlebitis and thrombophlebitis of superficial veins of upper extremities'], 'Chest discomfort': ['Other chest pain'], 'Hepatosplenomegaly': ['Leukemic reticuloendotheliosis'], 'Thrombocytopenia': ['Leukemic reticuloendotheliosis'], 'Numbness and tingling of fingertips': ['Leukemic reticuloendotheliosis'], 'Swollen arm': ['Phlebitis and thrombophlebitis of superficial veins of upper extremities'], 'Anxiety': ['Diabetes mellitus without mention of complication']}