tokens: 910458031 NVH 23238893 1/12/1991 12:00:00 AM Discharge Summary Signed DIS Admission Date : 01/12/1991 Report Status : Signed Discharge Date : 01/20/1991 PRINCIPAL DIAGNOSIS : METASTATIC ADENOCARCINOMA OF UNKNOWN PRIMARY . SECONDARY DIAGNOSIS : INTRAUTERINE PREGNANCY AT 23 WEEKS . HYPERCALCEMIA . INFERIOR VENA CAVA OBSTRUCTION . IMPENDING SPINAL CORD COMPRESSION . IDENTIFICATION DATA : The patient is a 34-year-old female with a 22 week intrauterine pregnancy who was transferred from Bri Health with diffuse metastatic adenocarcinoma of unknown primary . HISTORY OF PRESENT ILLNESS : The patient was in her usual state of excellent health until July of 1991 when she first noted a left clavicular mass . Subsequently , the mass continued to increase in size . On 12/23 , she was seen by Dr. Stonge at Bri Health where a 3 x 7 cm left mid clavicular mass was noted . A fine needle aspirate of this mass reportedly revealed giant cell tumor . The patient was initially told that this was a benign tumor and that it could simply be watched and definitively treated after the delivery of her baby . Subsequently , the mass progressively increased in size and the patient had developed significant discomfort in this region . On 1/5 , the patient underwent a local tumor debulking at Bri Health under local anesthesia . The pathology , unfortunately , revealed an aggressive adenocarcinoma ( micropapillary type ; mucin producing ) . This prompted further staging work-up . The patient subsequently had a limited chest CT at Bri Health which showed diffuse bilateral pulmonary metastases , metastases to the sternum , rib , multiple spinal levels ; internal mammary lymphadenopathy . The poor prognosis for the patient and child were discussed and after the patient decided to have an elective abortion , an abdominal CT scan was obtained which revealed diffuse metastatic lesions of the liverspine , ribs and most of the lymph nodes . There was no obvious GIor pancreatic tumor identified . The patient had a very firm nodule at the vertex of her calvarium . A specimen was obtained by fine needle aspiration and the pathology of this was consistent with adenocarcinoma . The patient was transferred to Nimaconwood Valley Hospital for management of her cancer and termination of the pregnancy . Over the past four weeks , the patient reported progressive shortness of breath and mid thoracic back pain . She has had no motor weakness , abnormal sensation , numbness , tingling or incontinence of bowel or bladder . She denied fevers , chills or sweats . There has been no GI or GU symptoms except for constipation . PAST MEDICAL HISTORY : Unremarkable . MEDICATIONS : On admission included Percocet for pain and multivitamins . ALLERGIES : NO KNOWN DRUG ALLERGIES . FAMILY HISTORY : The patient &apos;s father died at age 69 with metastatic prostate cancer . The patient &apos;s sister has a history of cervical cancer . SOCIAL HISTORY : The patient is married and lives with her husband . She has no children . She is a nonsmoker . She drinks socially . She has not had any alcoholic beverages during this pregnancy . PHYSICAL EXAMINATION : On admission revealed a pleasant , comfortable , tired appearing female . The patient was afebrile . Blood pressure was 98/64 . Pulse 82 . Respiratory rate 20 . Skin exam revealed a right posterior parietal scalp nodle measuring 2 x 3 cm which was very firm . There was a 1 cm firm nodule at the left upper thoracic region of the back between the midline and the scapula . There was a 1 cm firm nodule in the right upper quadrant of the abdomen . HEENT exam was unremarkable . Neck was supple . There was no jugular venous distention . There was no lymphadenopathy . Back was without CVA tenderness . There was no scapular tenderness . There was mild lower thoracic tenderness . Lungs were clear to auscultation . There were no rales or wheezes . There was no egophony . Cardiac exam was tachycardic and regular , normal S1 and S2 . There was a II / VI systolic ejection murmur loudest at the left upper sternal border . There was no heave . Abdomen was gravid . Bowel sounds were present . The abdomen was tympanitic and nontender . The liver was 11 cm by percussion . There was no liver edge palpable , no spleen tip palpable . Rectal revealed normal muscle tone , heme negative stool . Extremities revealed 1+ bipedal edema on admission . Neurological examination revealed the patient to be alert and oriented times three . Cranial nerves II - XII were intact . Motor was 5/5 . Sensation was intact to light touch . Deep tendon reflexes were 1-2+ and symmetric bilaterally . Toes were downgoing . LABORATORY DATA : On admission included an ALT of 108 , AST of 286 . Total bilirubin 3.0 , direct bilirubin of 2.0 . Alkaline phosphatase 1148 . LDH 806 . Calcium 11.8 . Albumin 2.3 . Hematocrit was 30.6 . White blood cell count was 11.14 . PT was 13.2 . PTT was 29.8 . HOSPITAL COURSE : The patient had an elective termination of her pregnancy on 1/13/91 . The work-up for the extent of the patient &apos;s disease included MRI scan of the cervical and thoracic spine which revealed multiple metastatic lesions in the vertebral bodies ; a T3 lesion extending from the body to the right neural for amina with foraminal obstruction . An epidural mass was present at T10 which was extending from the lamina or spinous process anteriorly and almost compressing the spinal cord . An abdominal and pelvic CT scan with IV contrast revealed bilateral pulmonary nodules and bilateral pleural effusions , extensive liver metastases , narrowing of the intra hepatic IVC and distention of the azygous system suggestive of IVC obstruction by liver metastases ; ascites ; multiple bony metastases ; and an isolated splenic metastases . A bone scan revealed increased uptake in the left chest wall , left anterior ribs four to six , and increased uptake in the left and right lateral skull in the area of the parotids . Ahead CT scan revealed a metastatic lesion in the right vertex of the calvarium but no intracranial abnormalities . Work-up for the source of the primary tumor which is still unknown included a mammogram which identified no suspicious microcalcifications and no dominant masses . The abdominal and pelvic CT scans showed no suspicious GI masses , no pancreatic mass ; a 2 cm ovarian cyst . The review of the pathology from Bri Health confirmed a high grade adenocarcinoma . Erica and basic cystic protein stains are still pending . Serum markers were normal . The CEA was less than 0.7 . The hCG on admission was 30,710 and on 1/19 was 805 . The CA-125 was still pending and alphafeto protein is still pending . Hypercalcemia : The patient presented with a serum calcium of 11.8 and an albumin of 2.3 on admission . She received three days of intravenous etidronate with normal saline diuresis and the serum calcium subsequently decreased to 9.0 . The patient was then switched to po etidronate . IVC obstruction : The patient has extensive hepatic metastases and by CT scan there is obstruction of the intrahepatic IVC . This has resulted in marked bilateral lower extremity and presacral edema with ascites . The patient &apos;s low serum albumin is also contributing to her extensive edema . Hypoxia and shortness of breath : Although the patient &apos;s room air saturation was 96% during this admission , she subjectively complained of increased shortness of breath . It was felt that the patient &apos;s extensive pulmonary metastases and bilateral pleural effusions resulted in increased work of respiration and a sensation of shortness of breath . Impending spinal cord compression : The patient had back pain on admission without any focal neurological signs . The MRI scan on admission revealed an impending cord compression at the level of T10 . She was started on Decadron and on 1/17 began the first of ten radiation treatments to two fields ( T2 to T5 and T9 to T11 ) . Per the patient &apos;s wishes , Dr. Dalywoo Droreite the Windgo Hospital was consulted for a second opinion regarding the management of her malignancy . Dr. Linke recommended chemotherapy with PFL . Per the patient &apos;s wishes , she was transferred to the Windgo Hospital for chemotherapy . ALT was 53 . AST was 89 . Her LDH was 394 . Her alkaline phosphatase was 1514 . Total bilirubin was 2.1 . Direct bilirubin was 1.4 . Albumin was 2.3 . Calcium 9.1 . Hematocrit was 32.5 . White blood cell count was 16.89 . PT was 12.9 . PTT was 27.3 . DISPOSITION : MEDICATIONS : On discharge included etidronate , 475 mg IV q day ; heparin , 5000 units subcutaneously b.i.d. ; Decadron , 4 mg po q six hours ; MS Contin , 45 mg po b.i.d. ; Pepcid , 20 mg po b.i.d. ; Senekot , one tablet po t.i.d. ; Bronkosol , 0.25 cc q four hours . It was decided to have the patient &apos;s medical and oncological issues managed at Windgo Hospital . At the time of discharge , the patient &apos;s electrolytes were within normal limits . BD452/5255 RUTHU PAIN , M.D. KW25 D : 01/20/91 Batch : 8050 Report : H7691U2 T : 01/24/91 Dictated By : CEALME PAIN , M.D.