tokens: 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 &apos;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 :