DATE OF ADMISSION: MM/DD/YYYY
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.
