Nausea with vomiting Cough Fever unspecified Leukocytosis unspecified Dehydration Other specified cardiac dysrhythmias Nonspecific (abnormal) findings on radiological and other examination of abdominal area including retroperitoneum Other nonspecific abnormal finding of lung field Depressive disorder not elsewhere classified Other and unspecified hyperlipidemia Other B-complex deficiencies Cervical spondylosis without myelopathy Osteoarthrosis unspecified whether generalized or localized site unspecified Personal history of tobacco use Long-term (current) use of non-steroidal anti-inflammatories (NSAID) Intestinal bypass or anastomosis status
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Sulfa (Sulfonamide Antibiotics) / Codeine / Bactrim
 
Attending: ___
 
Chief Complaint:
nausea, vomiting, cough
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
___ female, with past medical history significant for 
depression, hyperlipidemia, Hysterectomy, B12 deficiency, back 
pain, carcinoid, cervical DJD, depression, hyperlipidemia, 
osteoarthritis, and history of Exploratory laparotomy, lysis of 
adhesions, and small bowel resection with enteroenterostomy for 
a high grade SBO ___ who presents with nausea, vomiting, 
weakness x 2 weeks. She has been uable to tolerate PO liquids, 
and solids. Had similar presentation ___ for high grade SBO. 
Denies passing flatus today. However reports having last normal 
bowel movement this AM, without hematochezia, melena. Also 
reporting subjective fever (100.0), non productive cough. Denies 
HA, myalgias. Takes NSAIDS sparingly. Denies alcohol use. Denies 
sick contacs/ travel or recent consumption of raw foods. Has 
never had a colonoscopy.  
.  
In ED VS were 97.8 120 121/77 20 98% RA  
Labs were remarkable for lactate 2.8, alk phos 293, HCT 33, WBC 
13.9  
Imaging: CT abdomen showed mult masses in the liver, consistent 
with malignancy. CXR also showed multiple nodules  
EKG: sinus, 112, NA, NI, TWI in III, but largely unchanged from 
prior  
Interventions: zofran, tylenol, 2L NS, GI was contacted and they 
are planning on upper / lower endoscopy for cancer work-up.  
.  
Vitals on transfer were 99.2 113 119/47 26 98%  

 
Past Medical History:
PMH: 
# high grade SBO ___ s/p exploratory laparotomy, lysis of 
adhesions, and small bowel resection with enteroenterostomy 
# carcinoid
# hyperlipidemia
# vitamin B12 deficiency
# cervical DJD
# osteoarthritis 

PSH: 
s/p R lung resection in ___ at ___
s/p hysterectomy in ___
s/p R arm surgery

 
Social History:
___
Family History:
non contributory
 
Physical Exam:
On admission

VS: 98.9 137/95 117 20 100 RA  
GENERAL: AOx3, NAD  
HEENT: MMM. no JVD. neck supple.  
HEART: Regular tachycardic, S1/S2 heard. no 
murmurs/gallops/rubs.  
LUNGS: CTAB, non labored  
ABDOMEN: soft, tender to palpation in epigastrium.  
EXT: wwp, no edema. DPs, PTs 2+.  
SKIN: dry, no rash  
NEURO/PSYCH: CNs II-XII intact. strength and sensation in U/L 
extremities grossly intact. gait not assessed.  

On Discharge: 
VS: 98.7   118/78   97  20 99RA
GENERAL: Patient is sitting in a chair, appears comfortable, 
A+Ox3, cooperative.   
HEENT: EOMI, PERRLA, No Pallor or Jaundice, MMM, no JVD, neck 
supple.  
HEART: RRR, no m/r/g.  
LUNGS: CTAB  
ABDOMEN: obese, soft, mild tenderness on mid +right epigastrium 
w/o peritoneal signs, no shifting dullness, difficult to 
appreciate organomegaly.  
EXT: wwp, no edema, no signs of DVT  
SKIN: no rash, normal turgor  
NEURO: no gross deficits 
PSYCH: appropriate affect, no preceptual disturbances, no SI, 
normal judgment.   

 
Pertinent Results:
___ 03:14PM   ___
___ 12:50PM URINE  HOURS-RANDOM
___ 12:50PM URINE  UHOLD-HOLD
___ 12:50PM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 12:50PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 
LEUK-TR
___ 12:50PM URINE  RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE 
EPI-2
___ 09:54AM   LACTATE-2.8*
___ 09:45AM   GLUCOSE-96 UREA N-7 CREAT-0.5 SODIUM-138 
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
___ 09:45AM   estGFR-Using this
___ 09:45AM   ALT(SGPT)-17 AST(SGOT)-46* ALK PHOS-293* TOT 
BILI-0.5
___ 09:45AM   LIPASE-14
___ 09:45AM   ALBUMIN-3.0*
___ 09:45AM   ___ AFP-1.7
___ 09:45AM   WBC-13.9* RBC-3.94* HGB-9.8* HCT-33.0* 
MCV-84# MCH-25.0*# MCHC-29.9* RDW-16.1*
___ 09:45AM   NEUTS-75.2* LYMPHS-17.9* MONOS-5.9 EOS-0.7 
BASOS-0.3
___ 09:45AM   PLT COUNT-657*#

CT abdomen/pelvis
1. Innumerable hepatic and pulmonary metastases.  No obvious 
primary 
malignancy is identified on this study. 
  
2. No evidence of small bowel obstruction, ischemic colitis, 
fluid collection, 
or perforation. 

CXR: 
 
New nodular opacities within both upper lobes, left greater than 
right. 
Findings are compatible with metastases, as was noted in the 
lung bases on the 
subsequent CT of the abdomen and pelvis performed later the same 
day. 

 
Brief Hospital Course:
___ Female with PMH significant for depression, 
hyperlipidemia, Hysterectomy, B12 deficiency, OA, carcinoid, 
cervical DJD, depression, SBO who presented with nausea, 
vomiting, weakness x 2 weeks and was found to have multiple 
liver and lung masses per CT consistent with metastatic cancer 
of unknown primary. 

Patient was treated with IV fluids overnight for dehydration. 
She refused to stay in the hospital for any further work-up or 
treatment and stated she would rather go home to to think and 
see to her affairs over the weekend and consider pursuing 
further work-up as an outpatient. She tolerated oral fluids well 
w/o vomiting. She remained hemodynamically stable and afebrile 
throughout her stay. 

Of note patient has psychiatric history of depressive symptoms 
and isolation tendencies. She denied any SI/SA or any risk to 
herself.  She has little social supports but does have a good 
relationship with her driver and friend who came in and was 
updated by the medical team on the morning of discharge and will 
be taking her home. She sees a mental health provider at ___ 
once a month and has a good relationship with her primary care 
physician. Patient was dischaerged home at her request. Home 
medications were continued to which we added some symptomatic 
treatment for her cough with benzonatate and Guaifenesin. We 
held off on anti-emetics for now as she did not want to stay 
inhouse to make sure these would be well tolerated (would need 
to monitor for drug interactions given multiple QTc prolonging 
and serotonergic medications on her home meds).  She was 
instructed to maintain good hydration and try a soft diet at 
home if she can not tolerate regular diet. The patient met with 
SW who provided her with resources for community councelling. 
Outpatient appointments with oncology, GI and her PCP were set 
up and her PCP and mental health provider were updated. Her PCP 
___ also ___ with her later today by telephone. 
 
Medications on Admission:
The Preadmission Medication list is accurate and complete
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing/SOB 
2. BuPROPion 150 mg PO DAILY 
3. Gabapentin 300 mg PO TID 
4. Ibuprofen 800 mg PO Q8H:PRN pain 
5. Sertraline 200 mg PO DAILY 
6. Simvastatin 40 mg PO DAILY 
7. Tizanidine 4 mg PO BID:PRN muscle spasms/pain 
8. traZODONE 100 mg PO HS:PRN sleep 
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID 

 
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 
2. BuPROPion 150 mg PO DAILY 
3. Gabapentin 300 mg PO TID 
4. Sertraline 200 mg PO DAILY 
5. Simvastatin 40 mg PO DAILY 
6. Tizanidine 4 mg PO BID:PRN muscle spasms/pain 
7. traZODONE 100 mg PO HS:PRN sleep 
8. Ibuprofen 800 mg PO Q8H:PRN pain 
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID 
10. Benzonatate 100 mg PO TID:PRN cough 
RX *benzonatate 100 mg 1 capsule(s) by mouth TID: PRN cough Disp 
#*60 Capsule Refills:*0
11. Guaifenesin ___ mL PO Q6H:PRN cough 
RX *guaifenesin 100 mg/5 mL ___ ml by mouth Q6H:PRN cough Disp 
#*1 Bottle Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Liver and Lung Mets of unkown primary

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

 
Discharge Instructions:
Dear ___, 

___ were seen in the ED for ongoing cough, nausea and vomiting 
and had imaging studies which unfortunately showed spots in your 
liver and lungs which are likely due to wide-spread cancer. ___ 
were admitted for further work-up and treatment of your 
symptoms. ___ chose to not have any more work-up in the hospital 
and wanted to be discharged home as soon as possible. 
Please make sure ___ keep well hydrated by taking water sips 
throughout the day. I also prescribed some symptomatic treatment 
for your nausea and cough. 
I updated your PCP and ___ and have set up ___ 
appointments as below.  
 
Followup Instructions:
___

{'nausea': ['Nausea with vomiting'], 'vomiting': ['Nausea with vomiting'], 'weakness': ['Nausea with vomiting'], 'cough': ['Cough'], 'fever': ['Fever'], 'leukocytosis': ['Leukocytosis'], 'dehydration': ['Dehydration'], 'cardiac dysrhythmias': ['Other specified cardiac dysrhythmias'], 'radiological findings': ['Nonspecific (abnormal) findings on radiological and other examination of abdominal area', 'Other nonspecific abnormal finding of lung field'], 'depressive disorder': ['Depressive disorder', 'not elsewhere classified'], 'hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'B-complex deficiencies': ['Other B-complex deficiencies'], 'cervical spondylosis': ['Cervical spondylosis without myelopathy'], 'osteoarthrosis': ['Osteoarthrosis', 'unspecified whether generalized or localized', 'site unspecified'], 'tobacco use': ['Personal history of tobacco use'], 'NSAID use': ['Long-term (current) use of non-steroidal anti-inflammatories (NSAID)'], 'intestinal bypass': ['Intestinal bypass or anastomosis status']}