Patient Name:
DOB:
Age/Sex:
50 years / Female
Admitting:
(HEMA) MD,
Attending:
(HEMA) MD,
E.
MR #:
FIN #:
Location:
Discharge Documentation
Document Name:
Document Status:
Performed By:
Authenticated By:
Discharge Summary
Signed
(HEMA) MD,
(HEMA) MD,
11:22 EDT
09:09 EDT
Discharge Summary
HIM Discharge Summary
DATE OF ADMISSION:
DATE OF DISCHARGE:
REASON FOR ADMISSION: Partial bowel obstruction with metastatic lobular cancer.
FINAL DIAGNOSIS:
1. Partial small-bowel obstruction versus ileus treated conservatively resolving at discharge.
2. Metastatic lobular carcinoma of the breast on Faslodex, likely progressing with worsening bone metastases, rising alkaline
phosphatase.
3. Anxiety disorder.
4. Gastroesophageal reflux disease.
5. Chronic airway disease.
6. Chronic pain secondary to breast cancer and osteoarthritis
7. Depression.
8. Decreased hearing with hearing aid implants and cholesteatoma operated on in 1993.
DISPOSITION: She is going home with followup in our office next week to discuss further hormonal manipulation or change in her
systemic therapy.
HOME MEDICATIONS:
1. She will continue on calcium.
2. PRN Zyrtec.
3. I have stopped her Neuvigil.
4. She has oxycodone 10 mg for pain q.6h. p.r.n.
5. She is on a 75 mcg Duragesic patch.
6. I have added Celebrex 200 mg a day.
7. She has Klonopin 0.5 mg t.i.d. p.r.n.
8. Cymbalta 30 mg a day.
9. Vitamin D 50,000 units weekly.
10. She has Nexium once a day.
11. Flonase nasal spray.
12. She has Singulair 10 mg a day for her respiratory status.
13. Topamax 50 mg b.i.d.
14. Effexor 150 mg a day.
PERTINENT LABS: Vital signs were stable throughout this hospitalization. Her discharge hemoglobin was 9.7. White count and
platelets were normal. Her alkaline phosphatase on the
was 152, it was 245 on the 14th. Albumin is low at 2.1, protein
Print Date:
13:45
Page 1 of 100
Chart Request ID:
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(HEMA) MD,
(HEMA) MD,
11:22 EDT
09:09 EDT
5.7. Magnesium, phosphorus were normal. Liver enzymes were normal. CA 27-29 was normal. Admission x-ray showed stable
chest with multiple left-sided rib fractures, possible pathological components, large lytic lesion of the left scapula, scattered air-fluid
levels in small bowel up to 3.6 cm, some lytic lesions in the left femur diaphysis and left femoral head. Follow up x-rays on the 13th
showed nonobstructive bowel gas pattern, mildly prominent loops of small bowel but air was seen in the rectosigmoid and colon and
transit of the contrast material in the colon. She had some rib x-rays because of chest wall pain on the 11th that showed expansile
aggressive appearing lytic foci in the lateral left 5th and 7th ribs and in the left 11th rib, changes in the left scapula were seen. There
were no spinal compressions. No lung parenchymal abnormalities.
HOSPITAL SUMMARY: The patient was admitted with metastatic breast cancer, currently receiving Faslodex first line hormone
therapy since
with extensive bone involvement. She had had radiation to her left shoulder and bilateral hips, finished
that about a week prior to admission. She had been on Xgeva as well. She developed flu symptoms and some diarrhea and she then
developed nausea, vomiting, lower abdominal pain. Abdominal CT and pelvis done in the office was consistent with a partial smallbowel obstruction, so she was admitted. She was seen in consultation by Dr.
He felt most likely this was an ileus but
could also be an obstruction. She was just treated with IV fluids and clear liquid. CT scan prior to admission had showed dilated
stomach and small bowel consistent with developing small-bowel obstruction, decompressed loops of distal ileum in the right lower
quadrant. There was no transition point. There was metastatic disease at L1. There was increasing size of the lytic lesions in the
pelvis. She had some loose bowel movements. Belly remained soft. On the
, diet was advanced. She had some pain in the left
upper abdomen and rib films showed the progressive lytic lesions in the ribs. We encouraged her to eat more and get up and walk.
On the morning of the 14th, she was eating, her belly was soft, she was having bowel movements, her vital signs were stable so am
discharging her.
Her cancer seems to be progressing in her bones and she appears to be failing Faslodex. She will discuss with Dr.
whether
to proceed to a trial of exemestane and Afinitor or transition to chemotherapy. We bumped her Duragesic to 75 mcg for pain control.
She has oxycodone for breakthrough. Her other medications are as detailed above.
MD
DD:
DT:
2 11:22:12
17:25:28
/
cc:
MD;
MD;
MD;
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ON:
09:09
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(HEMA) MD,
Page 2 of 100
Patient Name:
MR #:
FIN #:
History and Physical Reports
Document Name:
Document Status:
Performed By:
Authenticated By:
History & Physical
Signed
NP,
(HEMA) MD,
16:51 EDT
02:59 EDT
History & Physical
HIM History and Physical
DATE OF ADMISSION:
ADMITTING DIAGNOSIS: Partial small bowel obstruction, acute onset in the setting of a
patient with history of metastatic lobular breast cancer.
HISTORY OF PRESENT ILLNESS: Ms.
is a patient well known to Dr.
and
myself who is currently receiving treatment with Faslodex as first line hormone therapy
for metastatic breast cancer, progressed in
from stage III-C invasive lobular
breast cancer. She had extensive bony metastatic disease in the pelvis, right femoral
head, left pubic ramus, left ilium and left sacrum and the L5 vertebral body with seventh
rib fracture noted at metastatic disease onset. She completed radiation therapy to the
left shoulder and bilateral hips about one week ago. Ms
received doses of
Faslodex and Denosumab last week, the same day as the flu shot (
). Ms.
describes the symptoms with onset last Thursday after receiving a flu shot. She developed
generalized malaise, feeling hot and cold and flulike for a couple of days with
associated low abdominal discomfort and watery diarrhea for several days. The diarrhea
has improved; however, she continues with anorexia, mild nausea without vomiting, and
increasing left low abdominal pain. She presented as an unscheduled appointment today
for evaluation of symptoms.
Ms.
is afebrile in the office with normal blood pressure and heart rate. She was
evaluated with a CT abdomen and pelvis, due to exquisite pain, without rebound, of the
left lower quadrant. The CT was consistent with partial small bowel obstruction, with no
evidence of perforation or abscess. The patient is subsequently admitted for further
monitoring and surgical evaluation.
PAST MEDICAL HISTORY:
1.
invasive lobular breast cancer, left breast, ER-/PR-positive, HER-2/neu
negative
. Status post lumpectomy and node dissection; 18 of 21 regional nodes
involved with cancer, largest lymph node metastasis 4 cm. Status post adjunctive
chemotherapy with dose-dense AC followed by dose-dense Taxol x2. Due to Taxol
intolerance she was converted to Taxotere therapy. She then received breast irradiation
followed by hormonal blockade from
through
, discontinued due to
disesae progression.
2. Metastatic breast cancer established by CT scan in
2012 with extensive bony
disease. She was started on Faslodex in mid May, denosumab monthly was started on
Ms.
received radiation therapy in May to the cervical spine and
right shoulder and radiation to the left shoulder and both hips recently, completed last
).
3. Anxiety disorder.
4. GERD.
5. Headaches.
6. Chronic airway disease.
Page 7 of 100
Patient Name:
MR #:
FIN #:
History and Physical Reports
Document Name:
Document Status:
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Authenticated By:
History & Physical
Signed
NP,
(HEMA) MD,
16:51 EDT
02:59 EDT
7. Urinary incontinence.
8. Peripheral neuropathy.
9. Chronic pain secondary to breast cancer and osteoarthritis.
10. Osteoarthritis.
11. Depression.
12. Insomnia.
13. Bilateral hearing aid implants in
and cholesteatoma operated in
1993, history of ovarian cysts, history of kidney cysts.
FAMILY AND SOCIAL HISTORY: She is separated, but lives with a commited boyfriend who
accompanies her today. She has 2 children aged 21 and 26. She is disabled and is a
nonalcohol or tobacco product participant.
REVIEW OF SYSTEMS: As per history of present illness. Most significant complaint is
abrupt onset of lower abdominal pain associated with nausea, no vomiting, but increased
diarrhea several days prior to hospital admission. Generalized malaise with feeling hot
and cold but no actual febrile episodes documented.
PHYSICAL EXAMINATION:
GENERAL: This is a middle-aged African-American female in obvious distress.
VITAL SIGNS: Blood pressure is 129/83, heart rate of 80, respiratory rate of 18,
temperature 97.7, weight of 220.2 pounds. The patient is obese.
HEENT: No scalp lesions or scleral icterus. Multiple absent teeth noted and speech
pattern consistent with a chronic hearing problem and repaired cleft palate.
NECK: Supple without thyromegaly or adenopathy. Lymph node survey is negative.
LUNGS: Clear without rales, rhonchi or wheezes.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Diffusely soft, decreased to normal active bowel sounds. The patient is tender
throughout the mid abdomen with exquisite tenderness noted in the left lower abdomen. No
rebound. Mild guarding. No palpable mass noted.
EXTREMITIES: No cyanosis or clubbing. Persistent chronic bilateral symmetric pedal
edema is noted.
MUSCULOSKELETAL: No evidence of joint erythema, warmth or effusions. Decreased range of
motion of the left hip secondary to pain with abduction at the hip joint.
SKIN: No petechia, ecchymosis or rash. Hyperpigmentation noted in the left axilla and
shoulder at the site of recent radiation therapy.
LABORATORY DATA: WBC 3.0, hemoglobin 10.8, hematocrit 31.7, platelets of 167, ANC of
2.0, glucose 135, BUN 4, creatinine 0.9, sodium 137, potassium 3.3, bicarbonate of 26,
chloride 101, calcium 7.5 and magnesium 1.8.
X-RAYS AND SCANS:
CT abdomen and pelvis at
report
unavailable; however, verbal report from Dr.
consistent with partial small bowel
obstruction. No perforation or abscess.
CURRENT MEDICATIONS:
1. Ambien 10 mg at bedtime as needed for sleep
Page 8 of 100
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History and Physical Reports
Document Name:
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Performed By:
Authenticated By:
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Signed
(HEMA) MD,
16:51 EDT
E.
02:59 EDT
2. Arthritis pain topical relief capsaicin as needed.
3. Calcium 600 with vitamin D one tablet daily.
4. Diclofenac 50 mg as directed every 6 hours for pain
5. Flonase 50 mcg daily.
6. Klonopin 0.5 mg in the morning and 1 mg in the p.m.
7. Lastacaft drops 1 drop daily both eyes
8. Nexium 40 mg twice daily.
9. Potassium chloride 10 mEq daily.
10. Provigil 1 mg daily.
11. Replens 1 mg daily.
12. Saline nasal spray as needed.
13. Singulair 10 mg daily.
14. Topamax 50 mg twice daily
15. Toviaz 4 mg daily.
17. VESIcare 5 mg daily.
16. Vitamin B12 one tablet daily.
17. Zantac 2 tablets as needed for breakthrough GERD symptoms.
18. Celebrex 100 mg twice daily.
19. Cymbalta 30 mg daily.
20. Duragesic 50 mcg patch every 72 hours
21. Effexor 150 mg daily.
22. Magic mouthwash 10 mg swish and swallow a.c. and h.s. as needed
24. Oxycodone/acetaminophen 1 tablet every 4 hours as needed for breakthrough pain.
25. Promethazine 25 mg every 4 hours as needed for nausea.
Note all nonessential meds will be held during this admission.
IMPRESSION:
1. Radiographic findings and physical exam consistent with partial small bowel
obstruction.
2. Metastatic lobular breast cancer.
3. Chronic pain syndrome.
4. Nausea, vomiting, electrolyte imbalance secondary to #1.
5. Multiple comorbidities and polypharmacy.
PLAN: The patient is admitted for continued monitoring of the above-noted symptoms,
surgical consult will be requested. Follow up abdominal x-rays in the morning if no
exacerbations overnight and patient will be supported with IV hydration, electrolyte
supplementation, antiemetics and pain medications as needed.
Dictated for
M.D.
NP
Page 9 of 100
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Document Name:
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Authenticated By:
DD:
DT:
History & Physical
Signed
NP,
(HEMA) MD,
16:51 EDT
02:59 EDT
16:51:35
04:33:08
/
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ON:
08:02
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ON:
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NP,
(HEMA) MD,
Page 10 of 100
Patient Name:
MR #:
FIN #:
Consultation Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Consultation Note
Signed
(PROC) MD,
(PROC) MD,
21:27 EDT
21:23 EDT
Consultation Note
HIM Consultation Report
DATE OF CONSULTATION:
GASTROENTEROLOGY CONSULTATION
REFERRING PHYSICIAN: Dr.
REASON FOR CONSULTATION: Evaluation and management of possible small-bowel obstruction.
HISTORY OF PRESENT ILLNESS: This 50-year-old female patient has been admitted to the hospital with a history of abdominal
pain and nausea, and she has a history of stage III lobular carcinoma of the left breast. She had a lumpectomy and node dissection and
is going to have adjuvant chemotherapy. She was also found to have bone metastasis and she has been on Faslodex for that and for
the past day or two developed abdominal pain, nausea, and vomiting.
PAST MEDICAL HISTORY: Other past medical problems also include history of gastroesophageal reflux disease, chronic
obstructive pulmonary disease, and history of depression and insomnia.
PAST SURGICAL HISTORY: Left breast lumpectomy and lymphadenectomy axillary.
REVIEW OF SYSTEMS: As per examination.
PHYSICAL EXAMINATION:
GENERAL: She is somewhat dehydrated.
HEAD AND NECK: No lymphadenopathy, no masses.
RESPIRATORY: Both lungs have good air entry.
CARDIOVASCULAR: Both heart sounds are regular.
ABDOMEN: Soft, minimal to moderate distention. Tenderness mostly in the lower abdomen. Bowel sounds are mildly hyperactive.
Her abdominal x-rays revealed dilated bowel pattern with dilatation with a fluid pattern all the way to the colon.
LABORATORY DATA. BUN 2, creatinine 0.61.
IMPRESSION/PLAN: Based on x-ray pattern, this seems to be mostly ileus, but at this point because of the ileus pattern and also this
colonic dilatation that goes up to the left lower colon we do need to rule out a possibility of distal colonic lesions/colonic obstruction,
so plan is I will request for a CT scan abdomen and pelvis. In the meantime, since she started having bowel movement with diarrhea
at the same time, we can start her on a clear liquid diet, but I will continue to follow the patient.
Thank you for the consultation and allowing me to participate in the care of this pleasant female patient.
N
MD
Page 11 of 100
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FIN #:
Consultation Notes
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Authenticated By:
SNA:amp
DD:
DT:
Consultation Note
Signed
(PROC) MD,
(PROC) MD,
21:27 EDT
21:23 EDT
21:27:39
22:29:37
cc:
MD;
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ON:
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(PROC) MD,
Page 12 of 100
Patient Name:
FIN:
Page Number: 20
MRN:
Facility:
Patient Name:
MR #:
FIN #:
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Progress Note-Physician
Signed
NP,
(HEMA) MD,
11:02 EDT
02:59 EDT
Physical Exam
Chest: Clear
CV: RRR, No rubs, murmurs or gallops
Abdomen: obese, Soft, nontender, nondistended, hypoactive bowel sounds
Extremities: lympedema left arm
Objective
Vitals
Temp
36.5
BP
96/54
Pulse
77
24 Hr Tmax: 36.7 at
Totals
Intake
2999
RR
18
SPO2
----
O2 Therapy
-----------
14:00
Output
1902
Balance
1097
No 24 Hour Lab Data
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Signed
NP,
NP,
DVT/PE Exclsuion Criteria MD Entered
Entered On:
Performed On:
10:56 EDT
10:56 EDT
10:57 EDT
10:56 EDT by
NP,
DVT/PE Exclusion Criteria
Exclusion Criteria DVT/PE Pharma : Other: will order lovenox
NP,
Page 82 of 100
-
10:56 EDT
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Signed
(PROC) MD,
(PROC) MD,
21:17 EDT
14:57 EDT
Progress Note-Physician
HIM Progress Note - Physician
DATE OF SERVICE:
PHYSICIAN:
MD
The patient with history of lobar carcinoma of the breast admitted for a partial obstruction. Feeling better, had multiple liquid bowel
movements. Nausea has subsided and tolerating liquid diet, feeling well. Abdominal exam soft, nontender. Partial obstruction
resolving, possible ileus resolving, stable. Liquid diet and will advance diet as tolerated.
MD
DD:
DT:
21:17:42
04:46:04
/
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ON:
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ON:
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(PROC) MD,
Progress Note-Physician
Signed
(HEMA) MD,
(HEMA) MD,
08:54 EDT
:54 EDT
Subjective
some bloating,small loose bm yesterday
no emesis
ribs stable,finished xrt couple wks ago
Assessment/Plan
1. Metastatic lobular carcinoma of breast, on first line antihormonal therapy; CA 27-29, pending,
but not
elevated at metastatic diagnsis.
- Left upper thorax pain? question new area for lytic lesion. Will get rib films today.
lytic 5.7.scapula
2.
Partial small bowel obstruction, acute onset sx.
Concern re: possible intraabdominal metastasis in pt with lobular BrCa.
Repeat 3 way today.
Page 83 of 100
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FIN #:
Progress Notes
Document Name:
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Progress Note-Physician
Signed
(HEMA) MD,
(HEMA) MD,
08:54 EDT
08:54 EDT
GI surgery will help with management re: timing for clear liquids, expl surgery if sx
fail to
resolve.
Physical Exam
Chest: Clear
CV: RRR, No rubs, murmurs or gallops
Abdomen: Soft, nondistended, BS present; no rushes or tinkling.
min.Pain
guarding.
Extremities: No clubbing, cyanosis or edema
MS: pain with palpation left upper anterior thorax/rib area.
Objective
Vitals
Temp
36.8
BP
116/75
Pulse
83
24 Hr Tmax: 36.9 at
Totals
Intake
2315
RR
18
SPO2
----
O2 Therapy
-----------
14:40
Output
2550
Balance
-235
Today's Lab Results
06:32
Procedure
Units
Ref Range
BUN
2 L
mg/dL
7 - 18
Creatinine
0.73
mg/dL
0.60 - 1.10
Sodium Lvl
146 H
mmol/L
134 - 145
Potassium Lvl
4.2
mmol/L
3.5 - 5.1
CO2
27.0
mmol/L
21.0 - 32.0
Chloride
113 H
mmol/L
98 - 107
Glucose Lvl
92
mg/dL
65 - 99
Calcium Lvl
7.3 L
mg/dL
8.5 - 10.1
eGFR - African
>60
* eGFR - African - eGFR calculated by Discern Logic.
eGFR - Non-Afri
>60
* eGFR - Non-African - eGFR calculated by Discern Logic.
ALT
34
U/L
17 - 65
AST
23
U/L
3 - 37
Albumin Lvl
2.2 L
g/dL
3.4 - 5.0
Alk Phos
152 H
U/L
50 - 136
Bili Direct
<0.1
mg/dL
0.0 - 0.2
Page 84 of 100
today.
w/o rebound or
Patient Name:
MR #:
FIN #:
Progress Notes
Document Name:
Document Status:
Performed By:
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Signed
(HEMA) MD,
(HEMA) MD,
Bili Total
Total Protein
WBC
RBC
Hgb
Hct
MCV
RDW
Platelet
Neutro
Lymph
Mono
Eos
Basophil
Neutro Abs
0.1 L
5.8 L
3.5
2.90 L
9.2 L
27.8 L
95.8
17.1 H
170
68
9 L
8
16 H
0
2.38
08:54 EDT
08:54 EDT
mg/dL
g/dL
k/uL
M/uL
g/dL
%
fL
%
k/uL
%
%
%
%
%
k/uL
ELECTRONICALLY REVIEWED AND SIGNED
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0.2 - 1.0
6.4 - 8.2
3.5 - 10.5
3.90 - 5.03
12.0 - 15.5
35.0 - 44.0
82.0 - 98.0
12.0 - 15.0
150 - 450
42 - 78
16 - 52
1 - 11
0 - 7
0 - 4
2.10 - 6.30
(HEMA) MD,
(HEMA) MD,
Progress Note-Physician
Signed
(PROC) MD,
(PROC) MD,
15:37 EDT
15:37 EDT
colon rectal Surgery Progress Note
Subjective
No new complaints.
Had loose bm
no nausea
Assessment/Plan
AXR - improved dilatation
Resoloving ileus vs obstruction
Full liquid diet
Physical Exam
Chest: Clear
CV: RRR
Abdomen: Soft, nontender, nondistended, NABS
Extremities: WNL
Neck: Supple
Page 85 of 100
Patient Name:
MR #:
FIN #:
Progress Notes
Document Name:
Document Status:
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Authenticated By:
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Signed
(PROC) MD,
(PROC) MD,
15:37 EDT
15:37 EDT
Objective
Most Recent Vitals
Temp
BP
36.9
108/68
24 Hr Tmax: 37.1 at
Totals
Intake
3314
14:40
Pulse
RR
78
18
SPO2
95%
O2 Therapy
Room Air
21:33
Output
2800
Balance
514
Today's Lab Results
0826
eGFR - African
>60,
Magnesium
2.1,
0.70,
Sodium Lvl
146 H,
Potassium Lvl
Lvl
108 H,
Calcium Lvl
7.1 L,
eGFR - Non-Afri
>60,
BUN
1 L,
Creatinine
3.7,
CO2
25.0,
Chloride
115 H,
Glucose
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(PROC) MD,
Progress Note-Physician
Signed
NP,
(HEMA) MD,
08:00 EDT
03:03 EDT
Subjective
Left abdominal pain persists, nausea is worse when sitting upright. Tolerating clear liquids, no
vomiting.
Small semi solid stool yesterday, but several loose stools during the day. OOB walking a bit
yesterday.
CT was not reapted, report from monday CT in the chart. F/U abd films this am pending
c/o left upper chest/rib pain, shehas hx of multiple areas with bone mets.
Assessment/Plan
Page 86 of 100
Patient Name:
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FIN #:
Progress Notes
Document Name:
Document Status:
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Signed
NP,
(HEMA) MD,
08:00 EDT
03:03 EDT
1. Metastatic lobular carcinoma of breast, on first line antihormonal therapy; CA 27-29, pending,
but not
elevated at metastatic diagnsis.
- Left upper thorax pain? question new area for lytic lesion. Will get rib films today.
2.
Partial small bowel obstruction, acute onset sx.
Concern re: possible intraabdominal metastasis in pt with lobular BrCa.
Repeat 3 way today.
GI surgery will help with management re: timing for clear liquids, expl surgery if sx
fail to
resolve.
Physical Exam
Chest: Clear
CV: RRR, No rubs, murmurs or gallops
Abdomen: Soft, nondistended, BS present; no rushes or tinkling. Pain left lower mid abd
localized today.
more
w/o rebound or guarding.
Extremities: No clubbing, cyanosis or edema
MS: pain with palpation left upper anterior thorax/rib area.
Abdomenal films:
3 way abdomen this a.m. with persistent partial SBO
CT ABD/PELVIS CCNC RAL RAD: Dilated stomach, dilated loops of bowel of jejumun and
proximal ileum c/w developing SBO. Decompressed loop[s mall bowel right lower quad. No perforation
or free intraperitoneal air. Small volume pelvic ascities. Report in patient chart.
Objective
Vitals
Temp
36.7
BP
101/68
Pulse
76
24 Hr Tmax: 37.1 at
Totals
Intake
3314
RR
20
SPO2
----
21:33
Output
2800
Balance
514
Page 87 of 100
O2 Therapy
-----------
Patient Name:
MR #:
FIN #:
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
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Signed
NP,
(HEMA) MD,
08:00 EDT
03:03 EDT
No 24 Hour Lab Data
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Signed
(PROC) MD,
(PROC) MD,
07:38 EDT
07:38 EDT
Colon rectal / GISurgery Progress Note
Subjective
No new complaints.
Had liquid bm
Pain less, no vomitings
Assessment/Plan
Diffuse Ileus vs partial obstruction
CT scan abd today to define any component of mechanical obstruction
Clear liquid diet
Thanks
Physical Exam
Chest: Clear
CV: RRR
Abdomen: Soft, tender lower abdomen, no rebound,
Extremities: WNL
Neck: Supple
minimally distended, NABS
Objective
Most Recent Vitals
Temp
BP
36.7
102/46
24 Hr Tmax: 36.7 at
05:16
Pulse
RR
72
18
SPO2
----
05:16
Page 88 of 100
O2 Therapy
Room Air
Patient Name:
MR #:
FIN #:
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Progress Note-Physician
Signed
(PROC) MD,
(PROC) MD,
Totals
Intake
544
07:38 EDT
07:38 EDT
Output
900
Balance
-356
Today's Lab Results
0601
eGFR - Non-Afri
>60,
Phosphorus
2.8,
eGFR - African
>60,
BUN
2 L,
Creatinine
0.65,
Sodium Lvl
146 H,
Potassium Lvl
3.6,
CO2
25.0,
Chloride
115 H,
Glucose
Lvl
98,
Calcium Lvl
6.6 C,
WBC
2.7 L,
RBC
2.83 L,
Hgb
8.9 L,
Hct
26.7 L,
MCV
94.5,
RDW
16.4 H,
Platelet
153,
ELECTRONICALLY REVIEWED AND SIGNED
ON:
07:38
ELECTRONICALLY SIGNED
ON:
07:38
(PROC) MD,
Progress Note-Physician
Signed
NP,
(HEMA) MD,
Document Name:
Document Status:
Performed By:
Authenticated By:
(PROC) MD,
07:36 EDT
E.
03:03 EDT
Subjective
Left abdominal pain less today, and nausea is worse when sitting upright. Loose stools yesterday 34 episodes.
CT to be repeated today. Report from monday CT in the chart.
Assessment/Plan
1. Metastatic lobular carcinoma of breast, on first line antihormonal therapy; CA 27-29, pending,
but not
elevated at metastatic diagnsis.
2.
Partial small bowel obstruction, acute onset sx.
Concern re: possible intraabdominal metastasis in pt with lobular BrCa.
Repeat 3 way in a.m.
GI surgery will help with management re: timing for clear liquids, expl surgery if sx
fail to
resolve.
Physical Exam
Chest: Clear
CV: RRR, No rubs, murmurs or gallops
Abdomen: Soft, nondistended, BS present; no rushes or tinkling. Pain decreased but persistent at
left lower mid abd, w/o rebound or guarding.
Extremities:
No clubbing, cyanosis or edema
Page 89 of 100
Patient Name:
MR #:
FIN #:
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Progress Note-Physician
Signed
NP,
(HEMA) MD,
Abdomenal films:
3 way abdomen this a.m. with persistent partial SBO
07:36 EDT
03:03 EDT
: CT ABD/PELVIS CCNC RAL RAD: Dilated stomach, dilated loops of bowel of jejumun and
proximal ileum c/w developing SBO. Decompressed loop[s mall bowel right lower quad. No perforation
or free intraperitoneal air. Small volume pelvic ascities. Report in patient chart.
Objective
Vitals
Temp
36.7
BP
102/46
Pulse
72
24 Hr Tmax: 36.7 at
Totals
RR
18
SPO2
----
O2 Therapy
Room Air
05:16
Intake
544
Output
900
Balance
-356
Today's Lab Results
06:01
Procedure
Phosphorus
WBC
RBC
Hgb
Hct
MCV
RDW
Platelet
Units
mg/dL
k/uL
M/uL
g/dL
%
fL
%
k/uL
2.8
2.7 L
2.83 L
8.9 L
26.7 L
94.5
16.4 H
153
ELECTRONICALLY REVIEWED AND SIGNED
ON:
07:36
ELECTRONICALLY SIGNED
ON:
03:03
Ref Range
2.5 - 4.9
3.5 - 10.5
3.90 - 5.03
12.0 - 15.5
35.0 - 44.0
82.0 - 98.0
12.0 - 15.0
150 - 450
NP,
(HEMA) MD,
Page 90 of 100
Patient Name:
MR #:
FIN #:
Progress Notes
Progress Note-Physician
Signed
(HEMA) MD,
(HEMA) MD,
Document Name:
Document Status:
Performed By:
Authenticated By:
16:59 EDT
03:26 EDT
Subjective
Still with left abdominal pain.
No N/V.
Has had some loose stool.
No p.o. intake.
Assessment/Plan
1. Metastatic lobular carcinoma of breast, on first line antihormonal therapy;
will check CA 27-29.
Partial small bowel obstruction, acute onset sx.
Endoscopy unrevealing
Concern re: possible intraabdominal metastasis in pt with lobular BrCa.
Repeat 3 way in a.m.
Look to gi surgery re: timing for clear liquids, expl surgery if sx fail to
resolve.
2.
Physical Exam
Chest: Clear
CV: RRR, No rubs, murmurs or gallops
Abdomen: Soft, nondistended, BS present occ; no rushes or tinkling. Marked tenderness top direct
pressure left lower mid abd, w/o rebound or guarding.
Extremities:
No clubbing, cyanosis or edema
Abdomenal films:
3 way abdomen this a.m. with persistent partial SBO
Objective
Vitals
Temp
36.6
BP
101/55
Pulse
68
24 Hr Tmax: 37.0 at
Totals
RR
18
SPO2
----
O2 Therapy
-----------
22:22
Intake
818.5
Output
0
Balance
818.5
Today's Lab Results
04:33
Procedure
BUN
Creatinine
Sodium Lvl
Potassium Lvl
CO2
2 L
0.61
146 H
3.7
26.0
Units
mg/dL
mg/dL
mmol/L
mmol/L
mmol/L
Page 91 of 100
Ref Range
7 - 18
0.60 - 1.10
134 - 145
3.5 - 5.1
21.0 - 32.0
Patient Name:
MR #:
FIN #:
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Progress Note-Physician
Signed
(HEMA) MD,
(HEMA) MD,
16:59 EDT
03:26 EDT
Chloride
113 H
mmol/L
98 - 107
Glucose Lvl
79
mg/dL
65 - 99
Calcium Lvl
6.9 C
mg/dL
8.5 - 10.1
* Calcium Lvl - Results called to
RN by dma. Read back confirmed (Y/N)y at
6:55.
eGFR - African
>60
* eGFR - African - eGFR calculated by Discern Logic.
eGFR - Non-Afri
>60
* eGFR - Non-African - eGFR calculated by Discern Logic.
ELECTRONICALLY REVIEWED AND SIGNED
ON:
03:26
ELECTRONICALLY SIGNED
ON:
03:26
Document Name:
Document Status:
Performed By:
Authenticated By:
(HEMA) MD,
(HEMA) MD,
Progress Note-Nurse
Signed
RN,
RN,
07:34 EDT
07:34 EDT
Provider Notification/Callback Entered On:
Performed On:
7:35 EDT
7:34 EDT by
RN,
Provider Notification
Notification Call Reason : CRITICAL LABS/TESTS
RN,
7:34 EDT
RN,
7:34 EDT
Provider Notification Grid
Notified Date/Time
:
Notification
Provider/PA/NP :
Follow Up
Interventions :
7:34
EDT
No Order
Changes
RN,
7:34 EDT
Receipt of Results
Results
Date/Time Critical Result Received
Notification Critical Tests/Values : Lab
7:34 EDT
Page 92 of 100
Patient Name:
MR #:
FIN #:
Hematology
General Hematology
Procedure
Units
Ref Range
17:34 EDT
06:32 EDT
06:01 EDT
Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes
WBC
k/uL
[3.5-10.5]
5.9
3.5
2.7 L
RBC
M/uL
[3.90-5.03]
3.08 L
2.90 L
2.83 L
Differential
Hgb
g/dL
[12.0-15.5]
9.7 L
9.2 L
8.9 L
Hct
%
[35.0-44.0]
29.5 L
27.8 L
26.7 L
Platelet
k/uL
[150-450]
165
170
153
RDW
%
[12.0-15.0]
16.6 H
17.1 H
16.4 H
MCV
fL
[82.0-98.0]
95.9
95.8
94.5
Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes
Procedure
Units
Ref Range
06:32 EDT
Neutro
%
[42-78]
68
Lymph
%
[16-52]
9 L
Mono
%
[1-11]
8
Eos
%
[0-7]
16 H
Basophil
%
[0-4]
0
Neutro Abs
k/uL
[2.10-6.30]
2.38
Chemistry
General Chemistry
Procedure
Units
Ref Range
05:33 EDT
06:32 EDT
08:26 EDT
06:01 EDT
04:33 EDT
Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes
Sodium Lvl
mmol/L
[134-145]
143
146 H
146 H
146 H
146 H
Potassium Lvl
mmol/L
[3.5-5.1]
4.0
4.2
3.7
3.6
3.7
Chloride
mmol/L
[98-107]
108 H
113 H
115 H
115 H
113 H
CO2
mmol/L
[21.0-32.0]
30.0
27.0
25.0
25.0
26.0
BUN
mg/dL
[7-18]
7
2 L
1 L
2 L
2 L
Creatinine *
mg/dL
[0.60-1.10]
0.90
0.73
0.70
0.65
0.61
04:33 EDT Creatinine:
* This creatinine method is traceable to a GC-IDMS method and NIST standard reference material.
Procedure
Units
Ref Range
05:33 EDT
06:32 EDT
06:32 EDT
08:26 EDT
06:01 EDT
04:33 EDT
21:00 EDT
eGFR - African
eGFR - Non-African *
>60 f
>60 f
>60
>60
>60
>60
>60
>60
>60
>60
f
f
f
f
f
f
f
f
Glucose Lvl
mg/dL
[65-99]
89
92
108 H
98
79
Calcium Lvl
mg/dL
[8.5-10.1]
7.5 L
7.3
7.1
6.6
6.9
04:33 EDT eGFR - Non-African:
The eGFR is calculated using the four parameter MDRD equation for IDMS-traceable creatinine.
eGFR < 60 indicates chronic kidney disease, eGFR < 15 indicates kidney failure.
:33 EDT eGFR - African:
eGFR calculated by Discern Logic.
Page 93 of 100
Alk Phos
U/L
[50-136]
245 H
152 H
Bili Total
mg/dL
[0.2-1.0]
0.2
0.1 L
132
0.3
L
L
Cf
Cf
Patient Name:
MR #:
FIN #:
Chemistry
06:32 EDT eGFR - African:
eGFR calculated by Discern Logic.
08:26 EDT eGFR - African:
eGFR calculated by Discern Logic.
06:01 EDT eGFR - African:
eGFR calculated by Discern Logic.
04:33 EDT eGFR - African:
eGFR calculated by Discern Logic.
05:33 EDT eGFR - Non-African:
eGFR calculated by Discern Logic.
06:32 EDT eGFR - Non-African:
eGFR calculated by Discern Logic.
08:26 EDT eGFR - Non-African:
eGFR calculated by Discern Logic.
06:01 EDT eGFR - Non-African:
eGFR calculated by Discern Logic.
04:33 EDT eGFR - Non-African:
eGFR calculated by Discern Logic.
06:01 EDT Calcium Lvl:
Results called to
nurse by 73. Read back confirmed (Y/N)y at
04:33 EDT Calcium Lvl:
Results called to
RN by dma. Read back confirmed (Y/N)y at
Procedure
Units
Ref Range
05:33 EDT
06:32 EDT
08:26 EDT
06:01 EDT
21:00 EDT
Bili Direct
mg/dL
[0.0-0.2]
<0.1
Albumin Lvl
g/dL
[3.4-5.0]
2.1 L
2.2 L
Total Protein
g/dL
[6.4-8.2]
5.7 L
5.8 L
7:21.
6:55.
ALT
U/L
[17-65]
45
34
AST
U/L
[3-37]
43 H
23
Phosphorus
mg/dL
[2.5-4.9]
Magnesium
mg/dL
[1.8-2.4]
2.1
2.8
0.1
2.5 L
6.5
25
29
Immunology/Serology/Molecular Testing
Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes
Procedure
Units
Ref Range
06:08 EDT
CEA *
ng/mL
[0.0-5.0]
2.5
06:08 EDT CEA:
The Advia Centaur CEA is a twosite sandwich immunoassay using direct chemiluminometric technology. Results obtained from
other manufacturers' assay methods may not be used interchangably.
Page 94 of 100
Patient Name:
MR #:
FIN #:
References
Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes
Procedure
Units
Ref Range
06:01 EDT
Breast CA 27.29-Mayo
U/mL
[<=38.0]
<12.0 f
06:01 EDT Breast CA 27.29-Mayo:
The testing method is a chemiluminometric immunoassay
manufactured by Siemens and performed on the Siemen's Advia
Centaur.
Values obtained with different assay methods or kits may be
different and cannot be used interchangeably.
Test results cannot be interpreted as absolute evidence for
the presence or absence of malignant disease.
Test Performed by:
Laboratories Laboratory Director:
, M.D.
Diagnostic Radiology
Accession Number
Exam
DR Abdomen 1 View
Exam Date/Time
06:06 EDT
CPT4 Codes
74000 (DR Abdomen 1 View)
CDM Codes
25613 (DR Abdomen 1 View)
Reason For Exam
possible small bowel obstruction;Other-Please complete Reason For Exam free text
Report
INDICATION: Abdominal pain
FINDINGS: There is mild gaseous distention of small bowel loops
measuring up to 4.5 cm diameter. Oral contrast is present throughout
the colon extending to the rectosigmoid colon. The colon is
nondilated. Right upper quadrant clips are present.
IMPRESSION: Mild dilatation of small bowel with contrast throughout
Page 95 of 100
Ordering Physician
(HEMA) MD,
.
Patient Name:
MR #:
FIN #:
Diagnostic Radiology
Accession Number
Exam
DR Abdomen 1 View
Exam Date/Time
06:06 EDT
Ordering Physician
(HEMA) MD,
Exam Date/Time
10:56 EDT
Ordering Physician
(HEMA) MD,
the colon and the colon is nondilated. Findings are consistent with
partial small bowel obstruction.
***** Final *****
(RAD) MD,
Signed (Electronic Signature):
Signed by:
(RAD) MD,
Transcribed by:
Accession Number
6:32 am
Exam
DR Abdomen 3 Views
CPT4 Codes
74022 (DR Abdomen 3 Views)
CDM Codes
25614 (DR Abdomen 3 Views)
Reason For Exam
Other-Please complete Reason For Exam free text
Report
INDICATION: Abdominal pain
FINDINGS: AP supine and upright views of the abdomen and PA view of
the chest (2 views abdomen, 1 view chest) compared with the previous
examination dated
. Heart size and mediastinal contours are
normal. The lungs are clear. Left-sided rib fractures again
visualized. No free intraperitoneal air. A nonobstructive bowel gas
pattern is present. Right internal jugular Port-A-Cath is unchanged.
Interval transit of most of the previously seen contrast material in
the colon. Surgical clips consistent with cholecystectomy again
visualized. There are scattered mildly prominent loops of small bowel.
Air is seen in the rectosigmoid. No abnormal calcifications are seen
overlying the renal shadows or along the expected course of the
ureters. The visualized osseous structures are unremarkable.
IMPRESSION:
1. No evidence of cardiopulmonary disease. Stable left-sided rib
fractures.
2. Nonobstructive bowel gas pattern. Mildly prominent loops of small
Page 96 of 100
Patient Name:
MR #:
FIN #:
Diagnostic Radiology
Accession Number
Exam
DR Abdomen 3 Views
Exam Date/Time
10:56 EDT
Ordering Physician
(HEMA) MD,
Exam Date/Time
2 08:53 EDT
Ordering Physician
(HEMA) MD,
bowel visualized but air is seen in the rectosigmoid and colon.
Interval transit of previously seen contrast material in the colon.
***** Final *****
Jr. (RAD) MD,
Signed (Electronic Signature):
Signed by:
Jr. (RAD) MD,
Transcribed by:
Accession Number
1:28 pm
Exam
DR Abdomen 3 Views
CPT4 Codes
74022 (DR Abdomen 3 Views)
CDM Codes
25614 (DR Abdomen 3 Views)
Reason For Exam
SBO f/u;Other-Please complete Reason For Exam free text
Report
HISTORY: Left-sided abdominal pain, followup small bowel obstruction.
FINDINGS: Single view chest, flat and upright views of the abdomen.
Lungs are clear. No focal mass lesion or areas of consolidation.
Heart size and mediastinal contours normal. No effusion, pneumothorax
or free intraperitoneal air.
Flat and upright views of the abdomen show partial decompression of
mildly dilated small bowel loops in the central abdomen since the
previous study. Colon shows partial evacuation of remaining oral
contrast, and is not dilated.. Solid abdominal organ outlines normal.
No abnormal calcifications.
Lytic foci scattered to the axial skeleton again seen.
Page 97 of 100
Patient Name:
MR #:
FIN #:
Diagnostic Radiology
Accession Number
Exam
DR Abdomen 3 Views
Exam Date/Time
08:53 EDT
Ordering Physician
(HEMA) MD,
IMPRESSION: Interval improvement in partial small bowel obstruction
pattern. Bony lytic foci compatible with metastatic disease.
***** Final *****
(RAD) MD,
Signed (Electronic Signature):
Signed by:
(RAD) MD,
Transcribed by:
Accession Number
8:57 am
Exam
DR Abdomen 3 Views
Exam Date/Time
18:25 EDT
CPT4 Codes
74022 (DR Abdomen 3 Views)
CDM Codes
25614 (DR Abdomen 3 Views)
Reason For Exam
Abdominal Pain
Report
INDICATION: Abdominal pain. Vomiting.
COMPARISON:
.
FINDINGS: PA chest as well as supine and upright AP views of the
abdomen demonstrate cardiac and mediastinal silhouettes to be
unchanged. Right chest portacatheter again noted. No new focal
pulmonary opacity. Postprocedure sequela from left axillary node
dissection. Multiple left-sided rib fractures again noted, a with
probable pathologic components given the presence of small lucency.
Larger lytic lesion at the left scapula extending into the acromion
showing transverse dimension of 2.8 cm with probable pathologic
fracture. Evaluation of abdomen demonstrates contrast throughout much
of the colon with scattered gas fluid levels. Dilated small bowel
loops in the mid to left abdomen measuring up to 3.6 cm in diameter.
No evidence for perforation. No new soft tissue mass identified.
Irregularity involving the proximal left femoral diaphysis with with
lucent component. Lytic lesion also present within the inferior aspect
of left femoral head extending into the neck. Lucent regions also
present in the symphyseal distribution with cortical irregularity at
the left superior pubic ramus, most suggestive of pathologic fracture.
Page 98 of 100
Ordering Physician
(HEMA) MD,
Patient Name:
MR #:
FIN #:
Diagnostic Radiology
Accession Number
Exam
DR Abdomen 3 Views
Exam Date/Time
18:25 EDT
Ordering Physician
(HEMA) MD,
.
Exam Date/Time
08:53 EDT
Ordering Physician
(HEMA) MD,
IMPRESSION:
1. Findings suspicious for early, intermittent, or partial small bowel
obstruction with gas fluid levels throughout nondilated loops of
colon. No evidence for perforation.
2. Lytic lesion within the left scapula extending into the acromion
and suspected pathologic fracture. Additional suspected pathologic
left rib fractures and left superior pubic ramus fracture. Multiple
additional lytic lesions in the bilateral femurs, findings compatible
with osseous metastatic disease.
3. No evidence for acute cardiopulmonary disease.
***** Final *****
(RAD) MD,
Signed (Electronic Signature):
Signed by:
(RAD) MD,
Transcribed by:
Accession Number
7:24 pm
Exam
DR Ribs Unilateral Left
CPT4 Codes
71101 (DR Ribs Unilateral Left)
CDM Codes
35569 (DR Ribs Unilateral Left)
Reason For Exam
pain left anterior chest wall. HX metastatic breast cancer;Other-Please complete Reason For Exam free text
Report
HISTORY: Left chest wall pain
FINDINGS: AP and oblique views of the left chest wall. No fracture.
Mild expansile aggressive appearing lytic foci in the lateral left 5th
and 7th ribs, with an additional focus in the in the left 11th rib.
Lytic lesion in the scapula again seen. No spinal compression
Page 99 of 100
Patient Name:
MR #:
FIN #:
Diagnostic Radiology
Accession Number
Exam
DR Ribs Unilateral Left
Exam Date/Time
08:53 EDT
deformities. The included lung parenchyma is clear.
IMPRESSION: Bony metastases left chest wall and scapula.
***** Final *****
(RAD) MD,
Signed (Electronic Signature):
Signed by:
(RAD) MD,
Transcribed by:
9:07 am
Page 100 of 100
Ordering Physician
(HEMA) MD,