Encounter for antineoplastic chemotherapy Antineoplastic chemotherapy induced pancytopenia Other myeloid leukemia not having achieved remission Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH] Drug induced constipation 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: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
cycle 3 of hidac
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
Mr. ___ is a ___ male with history AML s/p 
7+3 induction now presenting for C3 of HiDAC. Developed FN after 
C2 of chemotherapy with no infectious source found and no 
further complications.

SUBJECTIVE: Patient is feeling well. No fevers since last 
admission, denies chills/rigors/uri sx. no recent n/v/d. did c/o 
gas pains a few days prior to admission that improved with 
simethicone prn.  He denies shortness of breath, cough, chest 
pain, abdominal pain, rashes, and dysuria
 
Past Medical History:
Past Medical History:

Patient presented to ___ with a 3 week history of 
weakness on ___. CBC revealed leukocytosis with blasts for 

which he was transferred to ___. Bone marrow biopsy confirmed 
acute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement. 
Patient was started on 7+3 on ___. Day 14 bone marrow with 

aplasia but persistent t(8;21) in 40% of cells per karyotype and 

RUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made 
not to re-induce. Day 21 bone marrow on ___ was with no 
morphologic or cytogenetic evidence of residual disease.

Treatment History:
- ___: 7+3
- ___: BMB with ___
- ___: C1D1 HiDAC
- ___: C2D1 HiDAC
- ___: C3D1 HiDAC
 
Social History:
___
Family History:
Both mother and father died of old age. He denies any family 
history of malignancy or blood disorders.
 
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Temp 97.8 BP 121/70 HR 77 RR 18, O2 sat 100%RA.
GEN: NAD.
HEENT: MMM, no OP lesions, no cervical, supraclavicular, 
axillary
adenopathy, no thyromegaly.
CV: RR, NL S1/S2 no S3S4 MRG.
PULM: CTAB.
GI: BS+, soft, NTND, no masses or hepatosplenomegaly.
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal 
adenopathy.
SKIN: No rashes or skin breakdown port site intact w/o erythema.
Pt does have darker brown skin lesions over anterior foreleg on
left but states chronic.
NEURO: A&Ox3. Cranial nerves II-XII are within normal limits.
Gross strength and sensation intact. no nystagmus, rapid hand
movements and tandem gait intact.

DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: TC 97.7 PO 110/62 97 18 96%RA
GEN: NAD, awake and alert x 3
HEENT: MMM, no OP lesions, no cervical, supraclavicular, 
axillary
adenopathy; no thyromegaly.
CV: RR, NL S1/S2 no S3/S4 MRG.
PULM: No increased WOB. CTAB.
GI: BS+, soft, NT/ND, no masses or hepatosplenomegaly.
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal 
adenopathy.
SKIN: No rashes or skin breakdown. Has darker brown skin lesions
over anterior foreleg on left which are chronic
NEURO: A&Ox3. Cranial nerves II-XII are within normal limits.
Gross strength and sensation intact. no nystagmus, rapid hand
movements and tandem gait intact. Cerebellar testing WNL
ACCESS: POC deaccessed at discharge
 
Pertinent Results:
___ 06:03AM BLOOD WBC-2.7*# RBC-2.96* Hgb-9.7* Hct-28.7* 
MCV-97 MCH-32.8* MCHC-33.8 RDW-16.5* RDWSD-58.8* Plt ___
___ 09:45AM BLOOD WBC-4.3 RBC-3.09* Hgb-10.1* Hct-30.3* 
MCV-98 MCH-32.7* MCHC-33.3 RDW-18.3* RDWSD-63.3* Plt ___
___ 06:03AM BLOOD Neuts-97.0* Lymphs-2.6* Monos-0.0* 
Eos-0.0* Baso-0.0 Im ___ AbsNeut-2.63# AbsLymp-0.07* 
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 09:45AM BLOOD Neuts-54.9 Lymphs-18.8* Monos-23.5* 
Eos-0.2* Baso-1.2* NRBC-1.2* Im ___ AbsNeut-2.34# 
AbsLymp-0.80* AbsMono-1.00* AbsEos-0.01* AbsBaso-0.05
___ 06:03AM BLOOD Plt ___
___ 09:45AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:03AM BLOOD Glucose-144* UreaN-15 Creat-0.6 Na-138 
K-4.1 Cl-100 HCO3-24 AnGap-18
___ 09:45AM BLOOD UreaN-10 Creat-0.8 Na-140 K-4.0 Cl-103 
HCO3-25 AnGap-16
___ 06:03AM BLOOD ALT-122* AST-71* LD(LDH)-186 AlkPhos-57 
TotBili-0.6
___ 09:45AM BLOOD ALT-83* AST-54* AlkPhos-72 TotBili-0.2
___ 06:03AM BLOOD Albumin-4.0 Calcium-8.8 Phos-4.1 Mg-2.3 
UricAcd-5.0
___ 09:45AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.___SSESSMENT AND PLAN: Mr. ___ is a ___ male 
with history AML s/p 7+3 presenting for C3 HiDAC consolidation.

C3D6 ___

#AML: Favorable genetics given t(8.21) s/p 7+3 and now 
presenting for C3 HiDAC consolidation. Bone marrow biopsy, FISH, 
and cytogenetics on day 21 of 7+3 indicate complete response. 
Tolerated this cycle w/o acute complications. Cerebellar exam 
was stable throughout all doses. Initiated on fluconazole and 
ciprofloxacin at discharge per primary team. Remains on 
acyclovir. Will continue on prednisolone eye drops until 
___. Has appointment on ___ with Dr. ___. 

#Pancytopenia (anemia, thrombocytopenia, neutropenia): stable 
now but expect to downtrend. Likely all consequence of 
chemotherapy and underlying malignancy and inflammatory block. 
Trend CBC with diff outpatient. 

#Transaminitis: Elevation in AST and ALT. No hyperbilirubinemia. 
Likely chemotherapy effect, continue to monitor and trend 
outpatient, consider RUQ U/S if worsens. 

#Constipation: on bowel regimen, stooling daily prior to 
discharge

Prophylaxes:
# Access: POC
# Contact: ___
# Disposition: Discharged on ___. RTC on ___ with Dr. 
___

# Code Status: Full
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H 
2. Ciprofloxacin HCl 500 mg PO Q12H 
3. Fluconazole 400 mg PO Q24H 
4. Montelukast 10 mg PO DAILY 
5. Simethicone 40-80 mg PO QID:PRN gas pain 

 
Discharge Medications:
1.  PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID 
Continue this eye drop until ___  
2.  Acyclovir 400 mg PO Q12H  
3.  Ciprofloxacin HCl 500 mg PO Q12H  
4.  Fluconazole 400 mg PO Q24H  
5.  Montelukast 10 mg PO DAILY  
6.  Simethicone 40-80 mg PO QID:PRN gas pain  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
AML

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

 
Discharge Instructions:
Mr. ___, 

You were admitted to receive your third cycle of chemotherapy 
(high dose cytarabine) for your leukemia. You tolerated this 
well and will be discharged today. Please restart your oral 
antibiotics (ciprofloxacin and fluconazole) to help prevent 
infection.

Please refer below for your outpatient appointment.

It was a pleasure taking care of you.

Sincerely,
Your ___ TEAM
 
Followup Instructions:
___

{'fevers': ['Encounter for antineoplastic chemotherapy', 'Antineoplastic chemotherapy induced pancytopenia'], 'chills/rigors/uri sx': ['Encounter for antineoplastic chemotherapy', 'Antineoplastic chemotherapy induced pancytopenia'], 'gas pains': ['Drug induced constipation'], 'shortness of breath': [], 'cough': [], 'chest pain': [], 'abdominal pain': [], 'rashes': [], 'dysuria': [], 'weakness': ['Other myeloid leukemia not having achieved remission'], 'leukocytosis with blasts': ['Other myeloid leukemia not having achieved remission'], 'aplasia': ['Other myeloid leukemia not having achieved remission'], 'persistent t(8;21)': ['Other myeloid leukemia not having achieved remission'], 'RUNX1/RUNX1T1 rearrangement': ['Other myeloid leukemia not having achieved remission'], 'elevation in AST and ALT': ['Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]'], 'anemia': ['Antineoplastic chemotherapy induced pancytopenia'], 'thrombocytopenia': ['Antineoplastic chemotherapy induced pancytopenia'], 'neutropenia': ['Antineoplastic chemotherapy induced pancytopenia']}