Disease of pericardium unspecified Acute upper respiratory infection unspecified Secondary malignant neoplasm of unspecified lung Personal history of malignant neoplasm of pancreas Hyperlipidemia unspecified Hypothyroidism unspecified Gastro-esophageal reflux disease without esophagitis Major depressive disorder single episode unspecified Personal history of nicotine dependence Other specified anemias Diarrhea unspecified Insomnia unspecified Encounter for palliative care
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
tetracycline
 
Attending: ___.
 
Chief Complaint:
Fever
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
Ms. ___ is a ___ female with history of
Stage IA (ypT1N0M0) PDAC s/p neoadjuvant FOLFIRINOX, SBRT,
Whipple (___), adjuvant FOLFOX, now with metastatic disease
to the lung on Rexahn trial (DF/___ trial ___ who presents
with fever.

The patient was admitted 5 months ago with high grade fevers due
to pan-sensitive klebsiella bacteremia of unclear source. Since
discharge, the patient had been doing well, but had continued to
have low grade fevers 99-100 which was attributed to her
chemotherapy which improved with taking dexamethasone. over the
last week or so, the patient had noticed increased fatigue and
dizziness, with persistently low grade fevers ~100. She 
contacted
her outpatient oncologist who recommended she keep a close eye 
on
her temperature. The day prior to admission it spiked to 103.

In addition, over the last few days, she has had increased
rhinorrhea and sinus congestion, but states she has had milder
versions of these symptoms throughout the winter. In addition 
she
has had a mild headache without vision changes. Furthermore, 
over
the last ___ days, she has had positional, substernal chest pain
which she described as throbbing. It is constant, without
radiation and exacerbated with deep breaths and lying flat. It 
is
relieved with leaning forward. It is not associated with dyspnea
and is without radiation.

Lastly, over the last 3 weeks, she has had intermittent loose,
non-bloody stool up to 3 times per day. 2 days ago she took
Imodium which stopped her BMs. She has not have a BM since.

Given her fever, she presented to ___ ED for further
evaluation. 

She initially presented to ___ where vitals were Temp
103.1, BP 103/74, HR 110, RR 18, and O2 sat 94% RA. Labs were
notable for WBC 6.5, H/H 9.0/27.6, Plt 414, Na 131, K 4.4, 
BUN/Cr
___, phos 2.2, Mg 1.7, LFTs/lipase wnl, lactate 2.1, and UA
negative. Blood cultures were sent. CXR was negative. CTA chest
was negative for pneumonia but remonstrated metastatic disease.
She was given zosyn, Tylenol, ibuprofen, and NS. She was
transferred to the ___ ED.

On arrival to the ED, initial vitals were 98.6 79 100/62 18 94%
RA. Exam was notable for stenal tenderness to palpation. Labs
were notable for WBC 4.0, H/H 8.5/26.3, Plt 326, Na 139, K 4.1,
and BUN/Cr ___. Influenza A/B PCR was negative. ECG showed 
NSR
with inferior Q waves.

Of note, the patient was admitted with sepsis in ___ due to
pan-sensitive klebseilla bacteremia without obvious source.

On arrival to the floor, patient reports the above history and
feels slightly more energized. She has no fevers or chills. 
Chest
pain as noted above. No dyspnea or abd pain. No dysuria.
 
Past Medical History:
- Pancreatic CA
- Hyperlipidemia 
- Hypothyroidism
- GERD
- Depression
- Nephrolithiasis
- Right Breast ALH in ___ s/p excision
- s/p remote eye surgery to correct strabismus she had when she
was a child
 
Social History:
___
Family History:
She notes that her mother had an episode of "jaundice" at ___ or 
___ years, was diagnosed with colon cancer at age ___, and died 6 
months later. Grandmother died from "septicemia," abdominal 
causes. She is ___ of five children, all in good health. Sister 
with ___ disease. 
 
Physical Exam:
GEN: Well appearing pleasant Caucasian woman sitting up in bed
HEENT: Oropharynx clear, MMM, sclerae anicteric
___: RRR no murmurs
RESP: CTAB
ABD: Soft, nontender, nondistended
EXT: warm, no peripheral edema
SKIN: Dry, no rashes
NEURO: alert, fluent speech, answers questions appropriately, 
PERRL, palate elevates symmetrically
ACCESS: POC c/d/i

 
Pertinent Results:
PERTINENT LABS:

Blood culture x 2 (___) ___ NGTD
Blood culture x 3 (___) ___ NGTD
Rapid Flu PCR (___): Negative
Respiratory Viral Screen (___): inadequate sample

PERTINENT IMAGING
CXR ___ at ___
1. Linear opacity in the left lower lobe likely due to linear 
atelectasis noted.
2. Slightly enlarged heart. Right venous catheter in place.

CTA Chest ___ at ___
1. Large irregular right lower lobe lesion with numerous nodules 
bilaterally.
2. no acute thoracic abnormality seen otherwise.
 
Brief Hospital Course:
___ with metastatic pancreatic cancer and history of klebsiella 
bacteremia, who presented from home with fevers to 103, 
rhinorrhea, congestion, and substernal chest pain. 

#Fevers
Presented with fever to ___ with URI symptoms and suspected 
pericarditis (substernal chest pain that was worse with lying 
flat and better with sitting forward). Given her previous 
history of klebsiella bacteremia and immunosuppression in the 
setting of chemotherapy, she was started on broad spectrum 
antibiotics. Blood cultures were unrevealing and she had no 
further episodes of fever while hospitalized. Her antibiotics 
were peeled off and ultimately stopped on the morning of 
discharge. 

EKG was unchanged from prior. A TTE was considered, but her 
pericarditis symptoms self-resolved with supportive care and was 
deferred. 

# Metastatic Pancreatic Adenocarcinoma:
# Secondary Neoplasm of Lung: 
Currently on Phase ___ trial ___ of RX-3117 (oral cytidine 
analogue) + abraxane. She will follow up tomorrow in clinic for 
continuation of therapy
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon (lipase-protease-amylase) ___ unit 
oral TID W/MEALS 
2. Levothyroxine Sodium 125 mcg PO DAILY 
3. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 
4. Omeprazole 40 mg PO DAILY 
5. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 
6. Venlafaxine XR 150 mg PO DINNER 
7. Vitamin D ___ UNIT PO DAILY 
8. coenzyme Q10 200 mg oral DAILY 
9. colesevelam 625 mg oral BID 
10. turmeric 1  capsule oral DAILY 
11. Pyridoxine 50 mg PO DAILY 

 
Discharge Medications:
1.  coenzyme Q10 200 mg oral DAILY  
2.  colesevelam 625 mg oral BID  
3.  Creon (lipase-protease-amylase) ___ unit 
oral TID W/MEALS  
4.  Levothyroxine Sodium 125 mcg PO DAILY  
5.  LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea  
6.  Omeprazole 40 mg PO DAILY  
7.  Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 
 
8.  Pyridoxine 50 mg PO DAILY  
9.  Pyridoxine 50 mg PO DAILY  
10.  turmeric 1  capsule oral DAILY  
11.  Venlafaxine XR 150 mg PO DINNER  
12.  Vitamin D ___ UNIT PO DAILY  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Fever
Pericarditis
Metastatic pancreatic cancer

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

 
                             ___ MD ___
 
Completed by: ___

{'fever': ['Acute upper respiratory infection', 'Disease of pericardium'], 'rhinorrhea': ['Acute upper respiratory infection'], 'sinus congestion': ['Acute upper respiratory infection'], 'mild headache': [], 'positional substernal chest pain': ['Disease of pericardium'], 'loose non-bloody stool': []}