Encounter for antineoplastic chemotherapy Malignant neoplasm of ascending colon
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Scheduled admission for chemotherapy with ___.
 
Major Surgical or Invasive Procedure:
___ treatment.

 
History of Present Illness:
Patient is a ___ man with stage III colon cancer (T3, 
NO, MO) status post laparoscopic right colectomy. Pathology 
revealed a low grade tumor with ___ lymph nodes involved, clean 
margins. No LVI was noted. He started FOLFOX on ___. He is 
receiving oxaliplatin, leucovorin, and ___. Two days prior to 
admission was cycle 3, day 16.

He is admitted today for observation during ___ treatment due 
to concern that this might be causing neurotoxicity and possible 
seizure activity (he was noted to have muscle twitching/cramping 
during infusion previously). The plan is for continuous EEG 
monitoring during ___ infusion today.

On speaking with him today, he feels fine. He denies chest pain, 
shortness of breath, lightheadedness, dizziness, or confusion. 
He denies muscle cramps or twitching.
 
Past Medical History:
None.
 
Social History:
___
Family History:
One brother died of leukemia.

 
Physical Exam:
Vital signs: T 97.4, BP 108/75, HR 56, RR 18, sat 100% RA
General: awake, alert, oriented, in no distress; lying 
comfortably in bed
Heart: RRR, normal s1/s2
Lungs: clear bilaterally
Abdomen: soft, non-tender
Legs: non-edematous, well-perfused
Neuro: AAOx3, moving all extremities
 
Pertinent Results:
___ 09:56AM BLOOD WBC-5.7# RBC-4.53* Hgb-12.4* Hct-38.5* 
MCV-85 MCH-27.3 MCHC-32.2 RDW-15.1 Plt ___
___ 09:56AM BLOOD Neuts-80.1* Lymphs-10.7* Monos-7.8 
Eos-1.2 Baso-0.2
___ 09:56AM BLOOD ___ PTT-23.9 ___
___ 09:56AM BLOOD Glucose-132* UreaN-14 Creat-0.9 Na-138 
K-3.7 Cl-102 HCO3-25 AnGap-15
___ 09:56AM BLOOD ALT-93* AST-47* LD(LDH)-214 CK(CPK)-90 
AlkPhos-71 TotBili-0.3
___ 09:56AM BLOOD Albumin-3.8 Calcium-8.1* Phos-2.5* Mg-2.1
 
Brief Hospital Course:
Patient underwent ___ treatment without complication. He was 
monitored on EEG during the infusion. The EEG was then reviewed 
by neurology. Per their report there was no evidence of seizure 
activity. The twitches he experienced during chemotherapy 
previously may be due to peripheral nerve damage (from either 
___ or platinum), and neurology has recommended that he have an 
EMG as the next step in his evaluation.
 
Medications on Admission:
APREPITANT [EMEND] - 125 mg (1)-80 mg (1)-80 mg (1) Capsule, 
Dose
Pack - 1 Capsule(s) by mouth daily as directed
DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth BID x 3 days
Starting the evening of chemotherapy
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth every six (6)
hours as needed for nausea ___ repeat x 1 if no effect
WARFARIN - 1 mg Tablet - 1 Tablet(s) by mouth once a day 
continue
daily while port is in
IBUPROFEN [ADVIL] -  (Prescribed by Other Provider) - Dosage
uncertain

 
Discharge Medications:
APREPITANT [EMEND] - 125 mg (1)-80 mg (1)-80 mg (1) Capsule, 
Dose
Pack - 1 Capsule(s) by mouth daily as directed
DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth BID x 3 days
Starting the evening of chemotherapy
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth every six (6)
hours as needed for nausea ___ repeat x 1 if no effect
WARFARIN - 1 mg Tablet - 1 Tablet(s) by mouth once a day 
continue
daily while port is in
IBUPROFEN [ADVIL] -  (Prescribed by Other Provider) - Dosage
uncertain
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary diagnosis
Colon cancer

 
Discharge Condition:
Vital signs stable, afebrile.

 
Discharge Instructions:
You were admitted for treatment of colon cancer with ___ and 
monitoring on EEG for evidence of seizure activity. The 
treatment went without complication, and there was no seizure 
activity on EEG.
.
There have been no changes to your medications.
.
Please note your follow-up appointments below.
 
Followup Instructions:
___

{'muscle twitching/cramping': ['Malignant neoplasm of ascending colon'], 'chest pain': [], 'shortness of breath': [], 'lightheadedness': [], 'dizziness': [], 'confusion': [], 'muscle cramps': ['Malignant neoplasm of ascending colon'], 'twitching': ['Malignant neoplasm of ascending colon']}