Other gastritis without bleeding Antineoplastic chemotherapy induced pancytopenia Other myeloid leukemia not having achieved remission Gastro-esophageal reflux disease without esophagitis Dehydration Adverse effect of antineoplastic and immunosuppressive drugs initial encounter Other specified places as the place of occurrence of the external cause Other long term (current) drug therapy
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
epigastric abdominal pain
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
Mr. ___ is a ___ male with history AML s/p 
7+3 induction now s/p 3C of HiDAC. Developed FN after C2 of 
HiDAC with no obvious infectious source found now presenting 
with abdominal pain.

SUBJECTIVE: Patient c/o slight epigastric pain hx of this with 
previous chemotherapy cycles feels similar to prior. No fevers 
since last admission, denies chills/rigors/uri sx. pain ___ on 
pain scale feels "gas pains". no recent n/v/d.  He denies 
shortness of breath, cough, chest 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 98.2 BP 123/74 HR 96 RR 16 O2 sat 100% RA.
___: NAD.
HEENT: MMM, no OP lesions, no cervical, supraclavicular, 
axillary
adenopathy, no thyromegaly.
CV: RR, NL S1S2 no S3S4 MRG.
PULM: CTAB.
GI: BS+, soft, slight pain on palpation of epigastric region. 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 98.3 ___ 20 99-100%RA
GEN: NAD, awake and alert, non-toxic in appearance.
HEENT: MMM, no OP lesions, no cervical, supraclavicular, 
axillary
adenopathy, no thyromegaly.
CV: RR, NL S1S2 no S3S4 MRG.
PULM: Non-labored. CTAB.
GI: BS+, soft. Pain on palpation of epigastric region resolved.
No rebound tenderness. No palpable 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,
discharge or swelling. 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.
 
Pertinent Results:
LABS:

___ 09:45AM   PLT SMR-RARE PLT COUNT-9*#
___ 09:45AM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ 
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL 
OVALOCYT-OCCASIONAL TEARDROP-1+ BITE-OCCASIONAL
___ 09:45AM   NEUTS-4* BANDS-0 LYMPHS-96* MONOS-0 EOS-0 
BASOS-0 ___ MYELOS-0 AbsNeut-0.01* AbsLymp-0.19* 
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 09:45AM   WBC-0.2* RBC-2.37* HGB-7.7* HCT-21.5* MCV-91 
MCH-32.5* MCHC-35.8 RDW-14.5 RDWSD-48.2*
___ 09:45AM   CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-2.0
___ 09:45AM   LIPASE-21
___ 09:45AM   ALT(SGPT)-62* AST(SGOT)-30 ALK PHOS-82 TOT 
BILI-0.5
___ 09:45AM   GLUCOSE-128* UREA N-13 CREAT-0.8 SODIUM-140 
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-21* ANION GAP-19
___ 12:15PM   PLT COUNT-46*#
___ 11:45PM BLOOD WBC-0.4*# RBC-2.49* Hgb-8.2* Hct-22.4* 
MCV-90 MCH-32.9* MCHC-36.6 RDW-14.6 RDWSD-47.3* Plt Ct-21*
___ 11:45PM BLOOD Neuts-14* Bands-0 Lymphs-66* Monos-16* 
Eos-0 Baso-0 Atyps-4* ___ Myelos-0 AbsNeut-0.06* 
AbsLymp-0.28* AbsMono-0.06* AbsEos-0.00* AbsBaso-0.00*
___ 11:45PM BLOOD Plt Ct-21*
___ 11:45PM BLOOD Glucose-121* UreaN-12 Creat-0.7 Na-134 
K-4.0 Cl-100 HCO3-24 AnGap-14
___ 11:45PM BLOOD ALT-48* AST-23 LD(LDH)-106 AlkPhos-75 
TotBili-0.7
___ 11:45PM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.8 Mg-2.2

ECG ___

Clinical indication for EKG: R___.31 - Abnormal electrocardiogram 
[ECG] 
[EKG] 
  
Sinus rhythm. Possible inferior wall myocardial infarction. 
Somewhat early  R wave progression. Compared to the previous 
tracing of ___ the rate is now somewhat slower. Otherwise, 
unchanged. 
 
Brief Hospital Course:
ASSESSMENT AND PLAN: Mr. ___ is a ___ male 
with history AML s/p 7+3 and C3 HiDAC consolidation presenting 
with epigastric pain.

C3D17 ___

#Epigastric pain: (resolved), described as mild in nature and 
was minimal on exam, etiology likely GERD vs. gastritis related. 
Added protonix and simethicone on admission with improvement. 
Received IVF ___ overnight. No fevers throughout hospital 
course so no further workup necessitated as etiology of pain 
unlikely infectious in origin although we had a low threshold 
for initiating empiric antimicrobial given neutropenia. No 
nausea, vomiting or diarrhea. Patient eating and drinking well. 
Lipase WNL. CMV/EBV PCR pending at discharge. 

#AML: Favorable genetics given t(8.21) s/p 7+3 and now s/p C3 
HiDAC consolidation. Bone marrow biopsy, FISH, and cytogenetics 
on day 21 of 7+3 indicate complete response. Will continue 
acyclovir, fluconazole and ciprofloxacin. Received neulasta 
given ___ and expect counts recovery soon. Follow up 
arranged for lab check on ___ at ___ and ___ with 
primary team

#Panyctopenia (anemia, thrombocytopenia, neutropenia): counts at 
nadir secondary to recent cycle of HiDAC but showing signs of 
recovery. No e/o clinical blood loss currently. Likely all 
consequence of chemotherapy and underlying malignancy and 
inflammatory block. However, given downtrend of H/H on ___, 
received 1U of PRBCs on ___. Transfuse for hgb <7 and/or plt 
<10K. Will RTC to ___ on ___ for lab check as above. 

Prophylaxes:
# Access: POC
# Contact: ___
# Disposition: Discharged ___ RTC on ___ at ___ for 
labs and ___ for provider visit and labs
# 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.  Pantoprazole 40 mg PO Q24H  
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
Abdominal pain likely GERD/Gastritis
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 
Discharge Instructions:
Mr. ___,

You were admitted due to dehydration and abdominal upset which 
improved with IV fluids time and adding a medication for 
heartburn. You will be discharged home and follow up as stated 
below. Please do not hesitate to call in the meantime with any 
questions or concerns. It was a pleasure taking care of you.
 
Followup Instructions:
___

{'epigastric pain': ['Other gastritis without bleeding', 'Gastro-esophageal reflux disease without esophagitis'], 'neutropenia': ['Antineoplastic chemotherapy induced pancytopenia', 'Other myeloid leukemia not having achieved remission'], 'anemia': ['Antineoplastic chemotherapy induced pancytopenia', 'Other myeloid leukemia not having achieved remission'], 'thrombocytopenia': ['Antineoplastic chemotherapy induced pancytopenia', 'Other myeloid leukemia not having achieved remission'], 'dehydration': ['Dehydration'], 'adverse effect of antineoplastic and immunosuppressive drugs': ['Adverse effect of antineoplastic and immunosuppressive drugs'], 'initial encounter': ['initial encounter'], 'other specified places as the place of occurrence of the external cause': ['Other specified places as the place of occurrence of the external cause'], 'other long term (current) drug therapy': ['Other long term (current) drug therapy']}