493597270
CMC
86164445
3/17/1998 12:00:00 AM
ACUTE LEUKEMIA
Signed
DIS
Admission Date :
03/17/1998
Report Status :
Signed
Discharge Date :
04/12/1998
HISTORY OF PRESENT ILLNESS :
The patient is a 68 year old with acute leukemia .
The patient was in her usual state of health until about three weeks prior to admission when she began to notice increased weakness and bruising .
She presented to a Wood Emergency Department six days prior to admission .
Platelets were 9,000 , hemoglobin 9.5 , temperature was 100.4 .
The patient had a smear there consistent with ALL .
The patient was transferred to Norri Hospital .
REVIEW OF SYSTEMS :
No headache , no nausea , vomiting or diarrhea .
Some shortness of breath with allergies , particularly cats .
No chest pain .
The patient had been doing aerobics three times a week until a couple of weeks before admission .
PAST MEDICAL HISTORY :
The patient 's past medical history is significant for allergies , depression and anxiety , pleural thickening / asbestosis , chronic left bundle branch block , tonsillectomy , adenoidectomy , vein stripping ( 1968 ) , left wrist fracture ( 1994 ) , and hypercholesterolemia .
ALLERGIES :
The patient 's allergies include a questionable penicillin reaction ; however , the patient tolerated Ampicillin well .
The patient does not recollect what her reaction to penicillin was .
The patient also had a history of platelet reaction .
FAMILY HISTORY :
The patient 's family history was significant for a brother with colon cancer .
SOCIAL HISTORY :
The patient lives with her husband and she has three children .
PHYSICAL EXAMINATION :
The patient 's physical examination revealed a well-developed , well-nourished white female in no apparent distress .
Vital signs :
Temperature 98.2 , blood pressure 134/80 , respiratory rate 22 , pulse 102 .
HEENT examination was normocephalic and atraumatic .
Cranial nerves II-XII were grossly intact .
There was decreased hearing bilaterally .
The oropharynx was within normal limits with fillings and a partial upper plate .
The neck had a full range of motion , no lymphadenopathy .
The chest exam was clear to auscultation .
Cardiac exam revealed an S1 and an S2 and a diffuse 2/6 systolic murmur .
The abdomen was soft , nontender and nondistended with no guarding and no hepatosplenomegaly .
Bowel sounds were present .
The skin examination revealed the right breast had a dark two centimeter ecchymosis and the left medial thigh had two pale blue two centimeter macules .
LABORATORY DATA :
Admitting labs were :
Sodium 138 , potassium 4.2 , chloride 98 , BUN 21 , creatinine 0.7 , glucose 117 , white blood cell count 13,200 , hematocrit 22.5 , platelet count 40,000 .
AST 29 , ALK 151 , total bilirubin 0.2 , total protein 7.2 , albumin 4.3 , globulins 2.9 , calcium 8.9 .
PT 12.8 , PTT 19.1 .
Peripheral smear revealed blasts of 62% .
HOSPITAL COURSE :
A Hickman catheter was placed and the patient was begun on chemotherapy .
The regimen included cyclophosphamide , daunorubicin , prednisone , Vincristine and PEG-asparaginase .
The patient tolerated the chemotherapy regimen well .
The patient began neutropenic on day five of induction .
The patient 's liver function tests began to rise and she began to experience pulmonary symptoms including increased crackles .
The patient began to spike and a blood culture grew out Staphylococcusaureus .
The patient was begun on Gentamicin , Vancomycin and Piperacillin , which was changed to Gentamicin and Ceftazidime .
The patient continued to spike and was enrolled in a randomized trial , the patient was randomized to AmBisome antifungal treatment .
An abdominal MRI was performed to assess continued elevated liver enzymes ; however , the MRI was negative .
The patient was begun on Nafcillin due to continued spiking .
The patient began to experience urinary retention and was straight catheterized .
Thepatient developed a possible drug rash and Nafcillin was changed to Ancef .
The patient became constipated ; this resolved with laxatives .
The patient improved significantly and was thought to be ready for discharge by the 11th of April .
She will follow up with her primary oncologists , Dr A and Dr Dark , at IVMC , after her discharge .
DISCHARGE MEDICATIONS :
The patient 's discharge medications include the following :
1) Albuterol inhaler two puffs q.i.d. p.r.n. breathing difficulties .
2) Calcium gluconate 1000 mg p.o. q day .
3) Cefazolin one gram IV q.8h. x 13days .
4) Colace 100 mg p.o. b.i.d.
5) Lasix 40 mg p.o. q day .
6) Lactulose 30 milliliters p.o. q.2h. p.r.n. constipation .
7) Magnesium hydroxide 30 milliliters p.o. q day .
8) Miracle Creamtopical q day p.r.n. skin irritation .
9) Sarna topical b.i.d. p.r.n. itching .
10) Senna tablets , two tablets p.o. b.i.d.
11) Simethicone 80 mg p.o. q.i.d. p.r.n. gas pain .
12) Citrucel one tablespoon p.o. q day .
13) K-Dur 10 mEq x three , p.o. b.i.d.
14) Zoloft 25 mg p.o. q day .
15) Peridex 30 cc p.o. b.i.d. x 14 days .
16) Robituss in AC five to ten milliliters p.o. q.h.s. p.r.n. cough .
Dictated By :
AZEL HIBBSKAYS , M.D. CF66
Attending :
TELSHEY K. SWATLLEEBTIK , M.D. NJ38 ME089/6922
Batch :
43792
Index No. CHDNIR25 OK
D :
05/13/98
T :
05/13/98