DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
BRIEF HISTORY AND HOSPITAL COURSE: The patient is a (XX)-year-old Asian female with rectal cancer metastatic to lymph nodes, liver, and lung. She had recent progression of disease, despite chemotherapy with Erbitux and Camptosar.
We admitted the patient with fever. This developed 10 days prior to admission. She had been started on Tamiflu at an outside clinic, yet did not improve on this therapy. She subsequently had blood cultures in our office, which were negative. After 10 days of failure to improve as an outpatient, we arranged this admission.
At the time of admission, we arranged blood cultures, which were unrevealing. Urinalysis and urine culture was negative at the time of this dictation. To rule out an intra-abdominal area of infection, we obtained a CT scan of the abdomen and pelvis. This showed progression of metastatic disease in the liver.
Two large metastatic lesions had fused into a single 10 x 10 cm metastasis in the right lobe. A mass near the porta hepatis measured 2.5 cm. There were enlarged retroperitoneal lymph nodes. The lower lung fields showed an area of infiltrate and atelectasis at the right lung base, new since the previous examination. This area of her abnormality was not visible on the chest x-ray. The patient had rales audible in this area.
We initially started a combination of cefepime and metronidazole and stopped metronidazole when we found no infection within the abdomen. The patient rapidly improved. Her temperature rose to 100.6 degrees Fahrenheit on the day following admission, then remained normal the final 36 hours of her hospital stay.
At that point, we changed antibiotic therapy to Ceftin 250 mg p.o. b.i.d. and allowed her to return home. The patient will also have Compazine 10 mg q.i.d. for nausea. She had relief of nausea with Zofran but could not afford this medication.
The patient will return to our office for followup of her metastatic rectal cancer. We suspect we will be unable to control that malignancy; although, we may attempt therapy with medications such as Xeloda. Unfortunately, the patient’s long-term prognosis is quite poor.
FINAL DIAGNOSES:
1. Fever, probably due to pneumonia.
2. Rectal cancer with extensive metastases.
