DATE OF DISCHARGE: MM/DD/YYYY

ADMISSION DIAGNOSIS: Right upper quadrant abdominal pain, possible pancreatitis.

FINAL DIAGNOSES:
1.  Hepatocellular carcinoma.
2.  Diabetes mellitus.
3.  Atelectasis, right lower lobe.

HOSPITAL COURSE:  We were consulted on admission and did see and evaluate for right upper quadrant pain, rule out pancreatitis and cholecystitis. We did gallbladder ultrasound, started IV H2 blocker, checked labs, chest x-rays, and EGD. On MM/DD/YYYY, the patient felt a little bit better, was still hurting some. The patient’s lungs were clear. Heart was regular. Abdomen was soft. Bowels sounds were positive. Extremities showed no edema. Hemoglobin 10.8 and hematocrit 33.0. White count 9500. Platelet count 382,000. Basic profile: Sodium 138, potassium 4.6, chloride 104, CO2 of 28, BUN 14, creatinine 1.0, and glucose 136. AST was 80, ALT was 114, amylase was less than 30, and lipase was 200.

The patient was scheduled for EGD. There was a liver lesion on ultrasound, had exploratory laparotomy three to four months ago, but no lesion could be found on gross evaluation of the liver. If additional workup is negative, we will discuss with Dr. (X) who did her surgery and see if her non-insulin-dependent diabetes mellitus was stable. Her EGD showed gastritis, mixed ulcers, and healed erythema. The patient would need CT of the abdomen to evaluate the liver lesion and will probably need a liver biopsy as well as exploration.

On MM/DD/YYYY, the patient felt a little bit better, was still having some pain. HIDA scan was normal. CT of the abdomen was pending. On MM/DD/YYYY, CT showed mass in the liver. The patient was still having pain, not really tolerating the diet. We will change to regular, admit, and do CT-guided biopsy, hopefully tomorrow. On MM/DD/YYYY, she was to have CT-guided liver biopsy. Today, her AST was 82 and her ALT was 96. Her hemoglobin was 9.8 and hematocrit was 29.0. White count was 7800. Platelet count was 364,000. On MM/DD/YYYY, she did undergo her CT-guided biopsy, and we are awaiting biopsy results.

She started having some right upper quadrant pain and shortness of breath. We will check chest x-ray. Her diabetes mellitus was stable. On MM/DD/YYYY, her pain seemed to be better but just does not feel well. Temperature was up to 101.2. She had some atelectasis and questionable pneumonia. We will continue with nebs and IV antibiotics. Her non-insulin-dependent diabetes mellitus was stable. Her potassium was down, would replace. Her hemoglobin was 9.4 and hematocrit was 27.4. White count was 7400. Platelet count was 362,000. Sodium was 140, potassium 3.5, chloride 106, CO2 of 28, and glucose 154. Albumin was 21. AST was 16, ALT was 92, and total bilirubin was 1.0. Her pathology was pending.

On MM/DD/YYYY, the patient still had some nervousness, was getting better. Nerves were getting the best of her. She had mild abdominal pain, no nausea, no vomiting. Temperature was up to 102.2. Pathology was still pending. Her atelectasis was increased. Temperature was increased. We will continue antibiotics and nebs.

For her anxiety, we will increase Ativan to 2 mg p.o. q.6-8 hours and Ambien 10 mg at bedtime p.r.n. Anemia, decreased H&H. We will recheck and transfuse if less than 8, and she will be continued over the next couple of days. Her biopsy was consistent with hepatocellular cancer, also x-fetoprotein increased.

We advised the patient and family, and the patient needs biopsy. The patient prefers Dr. (Y). If okay with Dr. (Z), we will consult Dr. (Y) and Dr. (X), and Oncology did see and evaluate as well. Oncology consult was discussed with Dr. (A) about possible transfer to Hepatology to have control of pain and further treatment. Her non-insulin-dependent diabetes mellitus was stable. For atelectasis and questionable pneumonia, we will get CT of the chest. Pain control was all that was advised on consult at this point with outpatient followup. The patient does have persistent infiltrate in the right lower lobe that may be due to compression from the lung mass. We will continue with IV antibiotics. Try MS Contin and possibly discharge tomorrow. On MM/DD/YYYY, she was doing okay. Pain was under reasonable control with T-max up to 100. Her hemoglobin was 9.7, hematocrit was 28.6, white count was 7200, and platelet count was 422,000. AST was 166, ALT was 312, and albumin was 2.2.

For her hepatocellular carcinoma, will get outpatient followup. We will continue her MS Contin for pain. For diabetes mellitus, we will send home with sliding scale insulin. For atelectasis, right lower lobe, probably due to liver mass, we will discharge home on p.o. Levaquin to follow up next week. The patient was given return appointment. Tests are pending, to be addressed in the office, and echocardiogram.

DISCHARGE MEDICATIONS:  Lotrel 5/10 mg daily, Synthroid 50 mcg daily, MS Contin 15 mg b.i.d., Protonix 40 mg daily, MSIR as needed for pain, Levaquin 500 mg daily for 5 days, and sliding scale insulin.

DIET:  The patient was placed on 1800-calorie ADA diet.

FOLLOWUP:  The patient to have followup appointments as above.

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DATE OF DISCHARGE:  MM/DD/YYYY

DIAGNOSES:
1.  Lymphoma.
2.  Human immunodeficiency virus.
3.  Chronic hepatitis C.
4.  Spinal stenosis.

PROCEDURES DONE DURING HOSPITALIZATION:
1.  Incision and placement of Ommaya reservoir.
2.  Chemotherapy Injection.

HISTORY OF PRESENT ILLNESS:  The patient is a pleasant (XX)-year-old male patient who at this time is undergoing treatment for a non-Hodgkin lymphoma. He also has history of HIV, on antiretroviral medication. The patient presented to the office recently with complaints of progressive lower extremity weakness, visual changes, and low back pain. He also described a progressive vocal hoarseness. Despite using narcotic analgesia at home, the patient was unable to control his pain, and he was therefore admitted for further evaluation and to rule out cord compression.

HOSPITAL COURSE:  Upon admission, the patient was placed on IV fluids. Labs were obtained. Urine culture was obtained. PCA morphine pump was ordered for narcotic analgesia. MRI was ordered of the LS spine and of the brain, and a consult was made to the neuro-oncologist for further evaluation. MRI of the brain obtained was unremarkable. MRI of the thoracic spine revealed mild thoracic degenerative disk disease with multiple small focal herniations, cord compression or stenosis not appreciated. Cord edema not identified. Abnormal enhancement is not seen at this time, but this does represent delaying imaging two hours after Magnevist administration. If more sensitive evaluation is needed, a dedicated MRI of thoracic spine with and without contrast can be performed. MRI of the L-spine revealed multilevel degenerative disk disease with moderate stenosis at L3-4, severe stenosis at L4-5, and foraminal stenosis at L5-S1. Left paracentral herniation with extruded disk fragment, L1-2, focal paracentral herniation, right lateral recess, L2-3, diffuse enhancement of surface of conus, filum, and descending nerve root sleeve, associated abnormal enhancement, left L4 nerve root sleeve, and left epidural space at L5-S1 pattern would be either inflammatory of more likely neoplastic in nature related to history of lymphoma. The patient will be brought back for imaging.

The patient did undergo evaluation by the neuro-oncologist whose recommendation was for a spinal tap. Spinal fluid was obtained. Pathology revealed a rare atypical lymphocyte consistent with involvement of lymphoma. Subsequent to these findings, a consult was made to the radiation specialist with regard to radiation therapy for a malignant carcinomatous meningitis.

The patient was then seen in evaluation by the neurosurgeon and underwent placement of a right Ommaya reservoir with ventricular catheter. The patient was seen by the infectious disease specialist to maintain his current antiretroviral cocktail therapy.

While admitted, the patient underwent administration of intrathecal chemotherapy, DepoCyt 50 mg. He did tolerate all treatments well with no complication noted, and once stable, was made ready for discharge home.

Consult was made to case management with regard to home care needs. Upon discharge, instruction was given with regard to medications and followup appointment. He will follow up with neurosurgeon and the neuro-oncologist in the next one to two weeks.

DISCHARGE MEDICATIONS:  New prescriptions were given to the patient for Zithromax, Septra, and hydrocodone. He was discharged on potassium, cyclobenzaprine and propoxyphene, as well as continued on Phenergan, allopurinol, Viramune, Zerit, Epzicom, prednisone, senna, Kytril, hydrocodone, azithromycin, acyclovir, nystatin, Levaquin, Aranesp, and Neulasta. The patient will follow up in our office in one week.

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