134300717
FIH
9099750
22777/5p0t
355178
2/23/1993 12:00:00 AM
DEEP VENOUS THROMBOSIS OF RIGHT LOWER EXTREMITY .
Unsigned
DIS
Report Status :
Unsigned
ADMISSION DATE :
2-23-93
DISCHARGE DATE :
2-24-93
PRINCIPAL DIAGNOSIS :
Deep venous thrombosis of right lower extremity .
ASSOCIATED DIAGNOSIS :
Metastatic melanoma .
HISTORY OF PRESENT ILLNESS :
This is the second Fairm of Ijordcompmac Hospital admission for Taroby Patient , a 70 year old male with a history of metastatic melanoma .
His melanoma was originally diagnosed last fall when he presented with lesions in the liver and spleen , and a chest CT showed left upper lobe nodules .
A head CT scan was negative , but an MRI scan of the spine showed an L5 metastasis with a fracture and had with epidural and paraspinal extension .
In addition , there was a T11 metastasis with cord compression .
Approximately one week ago , he was admitted to the Fairm of Ijordcompmac Hospital for chemotherapy with DTIC and Tamoxifen .
At that time , he also began radiation therapy to his lumbosacral spine .
He is continuing on the radiation therapy to date .
On February 23 , Mr. Patient presented to Dr. Patient 's office with two major symptoms .
First , he had right lower extremity swelling and lower extremity noninvasives confirmed the diagnosis of a femoral deep venous thrombosis .
Second , he had a witnessed episode in which his eyes rolled to the back of his head and there was a question of some seizure activity .
In the past , he has not been known to have a history of CNS metastases .
The episode of potential seizure activity occurred in the setting of a bowel movement and may have been associated with vasovagal activity .
PAST MEDICAL HISTORY :
The past medical history is as above .
FAMILY HISTORY :
Noncontributory .
REVIEW OF SYSTEMS :
The review of systems is negative , except as above .
ALLERGIES :
The patient has no known drug allergies .
PHYSICAL EXAMINATION :
The physical examination reveals a pleasant 70 year old male in no acute distress .
The blood pressure was 113/70 , pulse 66 , respirations 20 , and a temperature of 96.8 .
HEENT showed pupils equal , round , reactive to light and accommodation , and extra ocular movements intact .
The sclerae were anicteric .
The neck was supple , without jugular venous distention or increased thyroid .
Nodes :
There was no appreciable cervical , supraclavicular , axillary , or inguinal adenopathy .
The chest was clear to auscultation and percussion .
Cardiac :
regular rate and rhythm , with a I / VI systolic ejection murmur .
The abdomen showed a 10 cm liver with the edge palpable 2 fingerbreadths below the right costal margin .
The extremity exam was notable for 2+ pitting edema in the right lower extremity extending to the knee .
The neurological examination was nonfocal .
HOSPITAL COURSE :
Mr. Patient underwent venogram and inferior vena cava filter placement on February 23 , 1993 and was then he was admitted to the Fairm of Ijordcompmac Hospital for postoperative care .
He tolerated the procedure well .
In addition , the second major event that had occurred yesterday was a neurologic event of some kind .
Over the 24 hours of in house hospitalization , he did not have any further neurologic activity and was able to ambulate without assistance prior to discharge .
He will be scheduled for an MRI scan , Neurology consult , and an EEG next week as an out patient .
Mr. Patient was a poor candidate for anticoagulation because of his history of metastatic melanoma and the question of CNS metastases .
An IVC filter placement was accomplished without complication .
He is stable on February 24 and ready for discharge to home .
PROCEDURES :
IVC filter placement .
COMPLICATIONS :
None .
MEDICATIONS ON DISCHARGE :
Decadron 4 mg PO bid , Dilantin 100 mg PO tid .
CONDITION ON DISCHARGE :
Stable .
DISPOSITION :
Mr. Patient will be discharged to home .
He will have follow up arranged with Dr. Guabenfranda Patient .
ESTIMATED DISABILITY AND PROBABLE DURATION :
Permanent .
CA SHUFF , M.D.
DICTATING FOR :
GUABENFRANDA PATIENT , M.D.
TR :
it / bmot
DD :
2-24-93
TD :
02/26/93
CC :