910458031
NVH
23238893
1/12/1991 12:00:00 AM
Discharge Summary
Signed
DIS
Admission Date :
01/12/1991
Report Status :
Signed
Discharge Date :
01/20/1991
PRINCIPAL DIAGNOSIS :
METASTATIC ADENOCARCINOMA OF UNKNOWN PRIMARY .
SECONDARY DIAGNOSIS :
INTRAUTERINE PREGNANCY AT 23 WEEKS .
HYPERCALCEMIA .
INFERIOR VENA CAVA OBSTRUCTION .
IMPENDING SPINAL CORD COMPRESSION .
IDENTIFICATION DATA :
The patient is a 34-year-old female with a 22 week intrauterine pregnancy who was transferred from Bri Health with diffuse metastatic adenocarcinoma of unknown primary .
HISTORY OF PRESENT ILLNESS :
The patient was in her usual state of excellent health until July of 1991 when she first noted a left clavicular mass .
Subsequently , the mass continued to increase in size .
On 12/23 , she was seen by Dr. Stonge at Bri Health where a 3 x 7 cm left mid clavicular mass was noted .
A fine needle aspirate of this mass reportedly revealed giant cell tumor .
The patient was initially told that this was a benign tumor and that it could simply be watched and definitively treated after the delivery of her baby .
Subsequently , the mass progressively increased in size and the patient had developed significant discomfort in this region .
On 1/5 , the patient underwent a local tumor debulking at Bri Health under local anesthesia .
The pathology , unfortunately , revealed an aggressive adenocarcinoma ( micropapillary type ; mucin producing ) .
This prompted further staging work-up .
The patient subsequently had a limited chest CT at Bri Health which showed diffuse bilateral pulmonary metastases , metastases to the sternum , rib , multiple spinal levels ; internal mammary lymphadenopathy .
The poor prognosis for the patient and child were discussed and after the patient decided to have an elective abortion , an abdominal CT scan was obtained which revealed diffuse metastatic lesions of the liverspine , ribs and most of the lymph nodes .
There was no obvious GIor pancreatic tumor identified .
The patient had a very firm nodule at the vertex of her calvarium .
A specimen was obtained by fine needle aspiration and the pathology of this was consistent with adenocarcinoma .
The patient was transferred to Nimaconwood Valley Hospital for management of her cancer and termination of the pregnancy .
Over the past four weeks , the patient reported progressive shortness of breath and mid thoracic back pain .
She has had no motor weakness , abnormal sensation , numbness , tingling or incontinence of bowel or bladder .
She denied fevers , chills or sweats .
There has been no GI or GU symptoms except for constipation .
PAST MEDICAL HISTORY :
Unremarkable .
MEDICATIONS :
On admission included Percocet for pain and multivitamins .
ALLERGIES :
NO KNOWN DRUG ALLERGIES .
FAMILY HISTORY :
The patient 's father died at age 69 with metastatic prostate cancer .
The patient 's sister has a history of cervical cancer .
SOCIAL HISTORY :
The patient is married and lives with her husband .
She has no children .
She is a nonsmoker .
She drinks socially .
She has not had any alcoholic beverages during this pregnancy .
PHYSICAL EXAMINATION :
On admission revealed a pleasant , comfortable , tired appearing female .
The patient was afebrile .
Blood pressure was 98/64 .
Pulse 82 .
Respiratory rate 20 .
Skin exam revealed a right posterior parietal scalp nodle measuring 2 x 3 cm which was very firm .
There was a 1 cm firm nodule at the left upper thoracic region of the back between the midline and the scapula .
There was a 1 cm firm nodule in the right upper quadrant of the abdomen .
HEENT exam was unremarkable .
Neck was supple .
There was no jugular venous distention .
There was no lymphadenopathy .
Back was without CVA tenderness .
There was no scapular tenderness .
There was mild lower thoracic tenderness .
Lungs were clear to auscultation .
There were no rales or wheezes .
There was no egophony .
Cardiac exam was tachycardic and regular , normal S1 and S2 .
There was a II / VI systolic ejection murmur loudest at the left upper sternal border .
There was no heave .
Abdomen was gravid .
Bowel sounds were present .
The abdomen was tympanitic and nontender .
The liver was 11 cm by percussion .
There was no liver edge palpable , no spleen tip palpable .
Rectal revealed normal muscle tone , heme negative stool .
Extremities revealed 1+ bipedal edema on admission .
Neurological examination revealed the patient to be alert and oriented times three .
Cranial nerves II - XII were intact .
Motor was 5/5 .
Sensation was intact to light touch .
Deep tendon reflexes were 1-2+ and symmetric bilaterally .
Toes were downgoing .
LABORATORY DATA :
On admission included an ALT of 108 , AST of 286 .
Total bilirubin 3.0 , direct bilirubin of 2.0 .
Alkaline phosphatase 1148 .
LDH 806 .
Calcium 11.8 .
Albumin 2.3 .
Hematocrit was 30.6 .
White blood cell count was 11.14 .
PT was 13.2 .
PTT was 29.8 .
HOSPITAL COURSE :
The patient had an elective termination of her pregnancy on 1/13/91 .
The work-up for the extent of the patient 's disease included MRI scan of the cervical and thoracic spine which revealed multiple metastatic lesions in the vertebral bodies ; a T3 lesion extending from the body to the right neural for amina with foraminal obstruction .
An epidural mass was present at T10 which was extending from the lamina or spinous process anteriorly and almost compressing the spinal cord .
An abdominal and pelvic CT scan with IV contrast revealed bilateral pulmonary nodules and bilateral pleural effusions , extensive liver metastases , narrowing of the intra hepatic IVC and distention of the azygous system suggestive of IVC obstruction by liver metastases ; ascites ; multiple bony metastases ; and an isolated splenic metastases .
A bone scan revealed increased uptake in the left chest wall , left anterior ribs four to six , and increased uptake in the left and right lateral skull in the area of the parotids .
Ahead CT scan revealed a metastatic lesion in the right vertex of the calvarium but no intracranial abnormalities .
Work-up for the source of the primary tumor which is still unknown included a mammogram which identified no suspicious microcalcifications and no dominant masses .
The abdominal and pelvic CT scans showed no suspicious GI masses , no pancreatic mass ; a 2 cm ovarian cyst .
The review of the pathology from Bri Health confirmed a high grade adenocarcinoma .
Erica and basic cystic protein stains are still pending .
Serum markers were normal .
The CEA was less than 0.7 .
The hCG on admission was 30,710 and on 1/19 was 805 .
The CA-125 was still pending and alphafeto protein is still pending .
Hypercalcemia :
The patient presented with a serum calcium of 11.8 and an albumin of 2.3 on admission .
She received three days of intravenous etidronate with normal saline diuresis and the serum calcium subsequently decreased to 9.0 .
The patient was then switched to po etidronate .
IVC obstruction :
The patient has extensive hepatic metastases and by CT scan there is obstruction of the intrahepatic IVC .
This has resulted in marked bilateral lower extremity and presacral edema with ascites .
The patient 's low serum albumin is also contributing to her extensive edema .
Hypoxia and shortness of breath :
Although the patient 's room air saturation was 96% during this admission , she subjectively complained of increased shortness of breath .
It was felt that the patient 's extensive pulmonary metastases and bilateral pleural effusions resulted in increased work of respiration and a sensation of shortness of breath .
Impending spinal cord compression :
The patient had back pain on admission without any focal neurological signs .
The MRI scan on admission revealed an impending cord compression at the level of T10 .
She was started on Decadron and on 1/17 began the first of ten radiation treatments to two fields ( T2 to T5 and T9 to T11 ) .
Per the patient 's wishes , Dr. Dalywoo Droreite the Windgo Hospital was consulted for a second opinion regarding the management of her malignancy .
Dr. Linke recommended chemotherapy with PFL .
Per the patient 's wishes , she was transferred to the Windgo Hospital for chemotherapy .
ALT was 53 .
AST was 89 .
Her LDH was 394 .
Her alkaline phosphatase was 1514 .
Total bilirubin was 2.1 .
Direct bilirubin was 1.4 .
Albumin was 2.3 .
Calcium 9.1 .
Hematocrit was 32.5 .
White blood cell count was 16.89 .
PT was 12.9 .
PTT was 27.3 .
DISPOSITION :
MEDICATIONS :
On discharge included etidronate , 475 mg IV q day ; heparin , 5000 units subcutaneously b.i.d. ; Decadron , 4 mg po q six hours ; MS Contin , 45 mg po b.i.d. ; Pepcid , 20 mg po b.i.d. ; Senekot , one tablet po t.i.d. ; Bronkosol , 0.25 cc q four hours .
It was decided to have the patient 's medical and oncological issues managed at Windgo Hospital .
At the time of discharge , the patient 's electrolytes were within normal limits .
BD452/5255
RUTHU PAIN , M.D. KW25
D :
01/20/91
Batch :
8050
Report :
H7691U2
T :
01/24/91
Dictated By :
CEALME PAIN , M.D.