Fever unspecified Secondary malignant neoplasm of unspecified lung Diarrhea unspecified Hyperlipidemia unspecified Hypothyroidism unspecified Gastro-esophageal reflux disease without esophagitis Major depressive disorder single episode unspecified Personal history of malignant neoplasm of pancreas Personal history of nicotine dependence Menopausal and female climacteric states
 
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:
___ is a ___ yo woman with metastatic (lung)
recurrence of Stage IA (ypT1N0M0) PDAC (pancreatic CA) s/p
neoadjuvant FOLFIRINOX, SBRT, Whipple (___), adjuvant 
FOLFOX,
on Phase ___ DF/HCC ___ trial, who presents after C4D8 of
chemotherapy with fever to ___ F. 

Mrs. ___ was admitted twice early this month with fevers.
During her first admission (___) she was found to
have klebsiella bacteremia (pansensitive) possibly from GI 
source
and e coli UTI. She was discharged but returned later that day
with recurrent fever and URI symptoms. She completed a 14 day
course of ciprofloxacin ___. 

Yesterday (morning of chemotherapy), she had lower abdominal
cramps and loose bowel movement. Her stool was nonbloody and
watery with small "pieces". She otherwise felt well and 
presented
for C4D8. When she got home, she called her oncologist with a
fever, initially ___. Her fever persisted over several hours
with Tmax 102.2F. She also had 2 further loose bowel movements
that evening and presented to ___ for evaluation. 

At ___, she had low grade temps to 99.5. Basic labs
included WBC 4.9 and normal BMP/LFTs. She had a RUQ US and CXR
which were unrevealing. She received CTX given prior culture 
data
of pansensitive e coli and klebsiella and was transferred to
___.

In the ED here, her Tmax was 100.3F. 

On arrival to floor, Mrs. ___ states she has a resolving
tension headache, which usually accompanies her fevers. She does
not currently feel feverish or chilled. She denies
nausea/vomiting, dysuria. She reports resolving nasal congestion
and dry cough since her URI symptoms first developed during her
last admission (___). Her husband developed URI symptoms 2
weeks ago after her presumed viral URI. She denies suspicious
food intake or other sick contacts. 

 
Past Medical History:
Hyperlipidemia 
Hypothyroidism
GERD
depression
nephrolithiasis
Remote eye surgery to correct strabismus she had when she was
a child
hx right breast ALH ___ s/p excision at OSH
dry eyes
dry mouth since chemotherapy

Metastatic recurrence of pancreatic cancer:
Presented with transaminitis and malignant CBD stricture ___.
CTA showed 1.4 cm pancreatic head mass. She received 3 cycles of
neoadjuvant FOLFIRINOX (___), followed by SBRT
(___), and then Whipple ___. Her final pathologic
staging was T1N0 (1.3 cm PDAC in head of pancreas; ___ nodes,
negative margins, + PNI and grade II large vessel angiolymphatic
invasion). She received 3 cycles of adjuvant FOLFOX (___).
In ___, CT torso showed multiple subcm pulmonary nodules,
which were noted to increase on follow up CTs ___ and 
___.
A lung biopsy confirmed metastatic disease ___ and she was
consented and started on Phase ___ open label trial of RX-3117 
in
combination with abraxane at ___. C1D1 ___. 

 
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:
General:  Well appearing ___ woman sitting in chair 
HEENT:  Oropharynx clear, MMM, no lesions
CV:  RRR no murmur
PULM:  Clear bilaterally to auscultation
ABD:  Soft nontender nondistended, normoactive bowel sounds
LIMBS: No peripheral edema, WWP
SKIN:  No rashes
NEURO: Alert, oriented, provides clear history
ACCESS: R POC is accessed and c/d/i
 
Pertinent Results:
___ 06:00AM BLOOD WBC-2.5* RBC-2.62* Hgb-8.1* Hct-25.2* 
MCV-96 MCH-30.9 MCHC-32.1 RDW-16.8* RDWSD-58.4* Plt ___

TSH 1.5

- Micro -
U/A: bland 
UCx No growth

BCx x 2 pending (one from port, one peripheral): NGTD
Flu swab ___ ___ negative 
BCx x 2 ___ ___: NGTD
Norovirus negative
C diff PCR positive, but toxin NEGATIVE
Stool culture: negative

=======
IMAGING 
=======
RUQ ___ ___:
FINDINGS: The liver is diffusely echogenic consistent with 
severe fatty infiltration.

The patient is status post cholecystectomy.
The common duct measures 3 mm.

The right kidney measures 9.8 cm.
The right renal cortex is preserved.
There is no hydronephrosis in the right kidney.

The pancreas is not seen due to bowel gas.

IMPRESSION: Fatty infiltration of the liver.

CXR ___ ___:
The heart is not enlarged.

The lungs are clear bilaterally with normal pulmonary vascular 
distribution.

There is no pleural fluid.

A right-sided Port-A-Cath terminates in the distal superior vena 
cava.

IMPRESSION: No acute pulmonary infiltrates.

 
Brief Hospital Course:
___ with metastatic (lung) recurrence of Stage IA (ypT1N0M0) 
PDAC (pancreatic CA) s/p neoadjuvant FOLFIRINOX, SBRT, ___ 
(___), adjuvant FOLFOX, on Phase ___ DF/___ ___ trial, 
who presents after C4D8 of chemotherapy with fever to ___ F and 
3 episodes of loose stool. 

# Fever, diarrhea
Recently admitted (___) for fever after chemotherapy 
and was found to have klebsiella bacteremia (pansensitive) 
possibly from GI source and e coli UTI. She completed treatment 
with ciprofloxacin on ___.

She presented to ___ with fever to ___ shortly after 
C4D8 of chemotherapy. Initial workup included RUQ US and CXR 
which were unrevealing. 

She was started on ceftriaxone to treat empirically for the 
previous klebsiella bacteremia. Stool studies were sent and her 
C diff PCR returned positive. Ceftriaxone was discontinued and 
PO vancomycin was started. However, 12 hours later, her C diff 
toxin returned negative. All antibiotics were held and she was 
observed for 24 hours without recurrence of fever. 

The rest of her infectious workup was negative as noted in the 
previous section. This is Mrs. ___ ___ fever that has 
occurred after chemotherapy. Her case was discussed with her 
outpatient oncologist with the suspicion that her fevers are 
caused by her chemotherapy treatment. She will see her 
oncologist in follow up the week after discharge for further 
recommendations. 

[ ] outpatient plan for management of post-chemotherapy fevers

# Metastatic recurrence of Stage IA pancreatic adenocarcinoma 
s/p ___
On Phase ___ trial ___ of RX-3117 (oral cytidine analogue) + 
abraxane; s/p ___. 

Suspicion that fever is in setting of chemotherapy as above. Her 
trial drug ___-311___ was held for this cycle due to concern for 
infection. 

Please note for future admissions that Mrs. ___ home Creon 
is 3x the strength of BI formulary Creon. She tolerated a 
regular diet in the hospital with Creon 6 capsules with meals 
and 4 capsules with snacks. 

# Hot flashes
She reported hot flashes since initiation of chemotherapy. A TSH 
was checked, which returned normal after patient's discharge. 

[ ] inform patient of normal TSH 
 
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. Multivitamins 1 TAB PO DAILY 
5. Omeprazole 40 mg PO DAILY 
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. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 
11. Fish Oil (Omega 3) 1000 mg PO DAILY 
12. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 

13. Senna 8.6 mg PO BID:PRN Constipation - First Line 
14. turmeric 1  capsule oral 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.  Docusate Sodium 100 mg PO BID:PRN Constipation - First Line  

5.  Fish Oil (Omega 3) 1000 mg PO DAILY  
6.  Levothyroxine Sodium 125 mcg PO DAILY  
7.  LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea  
8.  Multivitamins 1 TAB PO DAILY  
9.  Omeprazole 40 mg PO DAILY  
10.  Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First 
Line  
11.  Senna 8.6 mg PO BID:PRN Constipation - First Line  
12.  turmeric 1  capsule oral DAILY  
13.  Venlafaxine XR 150 mg PO DINNER  
14.  Vitamin D ___ UNIT PO DAILY  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Fever with negative infectious workup

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

 
                             ___ MD ___
 
Completed by: ___

{'Fever': ['Fever', 'Secondary malignant neoplasm of unspecified lung', 'Diarrhea'], 'Diarrhea': ['Fever', 'Secondary malignant neoplasm of unspecified lung', 'Diarrhea'], 'Hot flashes': ['Hyperlipidemia', 'Hypothyroidism', 'Gastro-esophageal reflux disease without esophagitis'], 'Lower abdominal cramps': ['Major depressive disorder', 'single episode', 'unspecified'], 'Loose bowel movement': ['Personal history of malignant neoplasm of pancreas', 'Personal history of nicotine dependence'], 'Nasal congestion': ['Menopausal and female climacteric states']}