Other malignant lymphomas intrathoracic lymph nodes Unspecified pleural effusion Iatrogenic pneumothorax Pulmonary collapse Malignant neoplasm of thyroid gland Other acute postoperative pain Unspecified essential hypertension Unspecified acquired hypothyroidism Personal history of malignant neoplasm of breast Personal history of irradiation presenting hazards to health
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: CARDIOTHORACIC
 
Allergies: 
Penicillins / Codeine
 
Attending: ___.
 
Chief Complaint:
Recurrent effusions 
 
Major Surgical or Invasive Procedure:
___ Left video-assisted thoracoscopic surgery parietal 
pleural biopsy, effusion evacuation, and bronchoscopy.

 
History of Present Illness:
Mrs. ___ is an ___
woman with a history of breast cancer and newly diagnosed
thyroid nodule suspicious for papillary cancer who has now
presented with mediastinal lymphadenopathy which has grown
very quickly. She has had workup with an EBUS with biopsy of
level VII lymph node which showed suspicion for lymphoma. 
 
Past Medical History:
-  HTN
-  Hypothyroidism
-  Breast cancer x2, status post lumpectomy x2, status post XRT.

 
Social History:
___
Family History:
Mother: deceased breast cancer.
Father
___: Sister deceased MM, Brother deceased lymphoma
___
Other

 
Physical Exam:
PHYSICAL EXAM:          Height:               Weight:
Temp:  96.8   HR: 107      BP: 140/70  RR: 22 O2 Sat: 94% RA
GENERAL        [x] All findings normal
[ ] WN/WD  [ ] NAD  [ ] AAO  [ ] abnormal findings:

HEENT          [x] All findings normal
[ ] NC/AT   [ ] EOMI   [ ] PERRL/A   [ ] Anicteric
[ ] OP/NP mucosa normal     [ ] Tongue midline
[ ] Palate symmetric  [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:

RESPIRATORY    [ ] All findings normal
[x] CTA/P     [x] Excursion normal     [x] No fremitus
[ ] No egophony    [ ] No spine/CVAT
[ ] Abnormal findings: Decrease breath 

CARDIOVASCULAR [x] All findings normal
[ ] RRR    [ ] No m/r/g    [ ] No JVD   [ ] PMI nl  [ ] No edema
[ ] Peripheral pulses nl    [ ] No abd/carotid bruit
[ ] Abnormal findings:

GI             [x] All findings normal
[ ] Soft    [ ] NT   [ ] ND  [ ] No mass/HSM   [ ] No hernia
[ ] Abnormal findings:

GU             [x] Deferred  [ ] All findings normal
[ ] Nl genitalia    [ ] Nl pelvic/testicular exam    [ ] Nl DRE
[ ] Abnormal findings:

NEURO          [x] All findings normal
[ ] Strength intact/symmetric    [ ] Sensation intact/ symmetric
[ ] Reflexes nl     [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact   [ ] Abnormal findings:

MS             [x] All findings normal
[ ] No clubbing   [ ] No cyanosis   [ ] No edema   [ ] Gait nl
[ ] No tenderness  [ ] Tone/align/ROM nl   [ ] Palpation nl
[ ] Nails nl   [ ] Abnormal findings:

LYMPH NODES    [x] All findings normal
[ ] Cervical nl      [ ] Supraclavicular nl     [ ] Axillary nl
[ ] Inguinal nl   [ ] Abnormal findings:

PSYCHIATRIC    [x] All findings normal
[x] Nl judgment/insight    [x] Nl memory   [x] Nl mood/affect

 
Pertinent Results:
___ 04:22PM   POTASSIUM-3.4
___ 04:22PM   MAGNESIUM-1.7
___ 04:22PM   WBC-6.0 RBC-3.71* HGB-12.0 HCT-35.6* MCV-96 
MCH-32.5* MCHC-33.8 RDW-14.0
___ 04:22PM   PLT COUNT-341
___ 12:50PM OTHER BODY FLUID  CD23-D CD45-D ___ 
___ KAPPA-D CD2-D CD7-D CD10-D CD19-D CD20-D LAMBDA-D CD5-D
___ 12:50PM OTHER BODY FLUID  CD3-D
___ 12:50PM OTHER BODY FLUID  IPT-D
 
Brief Hospital Course:
Mrs. ___ is an ___ woman with a history of breast 
cancer and newly diagnosed thyroid nodule suspicious for 
papillary cancer who has now
presented with mediastinal lymphadenopathy which has grown
very quickly. She has had workup with an EBUS with biopsy of
level VII lymph node which showed suspicion for lymphoma.
Patient was brought to the OR for Left video-assisted 
thoracoscopic 
surgery parietal pleural biopsy, effusion evacuation, and
bronchoscopy.

Post-Op: Patient was stable with little pain on exam. CT was 
placed on suction and diet was advanced as tolerated. 

POD 1: Patient complained of mild incisional site pain with 
positive response to Dilaudid. She was started on Colace and 
maintained oxygen sat at 93-95% on 4L NC. She was subsequently 
weaned down to 2L NC. She continued to tolerated her diet and 
IVF were decreased. 

CXR: In comparison with prior study, there is little change in 
the 
appearance of the left chest tube and extensive opacification 
involving the 
lower half of the left lung. Dilatation of a gas-filled stomach, 
for which 
nasogastric tube might prove helpful.  

POD 2: Patient re-mained on telemetry w/o events. CT remained to 
suction with 
serosanguinous outputs. No leak was observed and no crepitus in 
the chest wall was appreciable. Patient was weaned to 1.5L NC 
and reported 1 BM. 

CXR: Unchanged left lower lobe and middle lobe opacity, 
consistent 
with post-surgical changes, or residual lung mass. Pneumonia 
cannot be ruled 
out, but is less likely. 

POD 3: CT placed to water seal. Patient was weaned of 02 and 
maintained sat's at 93% on RA. Pain was well controlled with 
Tylenol. Discharge planning was initiated and patient was 
thought to be fit for discharge home with services. Follow-up 
CXR showed findings listed below.

CXR:  Again seen is a left-sided chest tube. There is a new 
loculated 
pneumothorax in the left upper lung laterally.  

POD 4: Patient continued to be stable with good PO-intake, 
adequate UOP and minimal pain. Given recent CXR patient was kept 
for a day and Patient CT was clamped at 9:00pm. Repeat CXR 
showed stable loculation with no new pneumothorax. 

POD 5: Patient continued to be stable. CT was removed 
uneventfully and post-pull CXR was ordered. Patient continued to 
be stable with stable vital prior to discharge. 
 
Medications on Admission:
Medications - Prescription
AMLODIPINE [NORVASC] -  (Prescribed by Other Provider) - Dosage
uncertain
ANASTROZOLE [ARIMIDEX] - 1 mg Tablet - one Tablet(s) by mouth
daily
LATANOPROST [XALATAN] -  (Prescribed by Other Provider) - Dosage
uncertain
LEVOTHYROXINE -  (Prescribed by Other Provider) - Dosage
uncertain
METOPROLOL SUCCINATE [TOPROL XL] -  (Prescribed by Other
Provider) - Dosage uncertain
PERSERVISION -  (Prescribed by Other Provider) - Dosage 
uncertain
TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] -  (Prescribed by Other
Provider) - Dosage uncertain

 
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
2. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().  
3. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) 
Tablet Sustained Release 24 hr PO once a day.  
4. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO once a day. 
 
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at 
bedtime).  
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six 
(6) hours as needed for pain for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for prn pain.  

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Left pleural effusion

 
Discharge Condition:
stable

 
Discharge Instructions:
Call Dr. ___ ___ if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develop drain: steri-strips remove if start to come 
off.
 
Followup Instructions:
___

{'Recurrent effusions': ['Other malignant lymphomas', 'Unspecified pleural effusion'], 'Mediastinal lymphadenopathy': ['Other malignant lymphomas', 'Intrathoracic lymph nodes'], 'Decrease breath': ['Iatrogenic pneumothorax', 'Pulmonary collapse'], 'Pain': ['Other acute postoperative pain'], 'Hypothyroidism': ['Unspecified acquired hypothyroidism'], 'Breast cancer': ['Personal history of malignant neoplasm of breast'], 'Thyroid nodule': ['Malignant neoplasm of thyroid gland']}