Lung Malignancy Discharge Summary Transcription Sample Report
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DIAGNOSES:
1. Malignancy of the bronchial lung.
2. Pleural effusion.
3. Metastatic malignancy to the liver.
4. Ascites.
5. Chronic airway obstruction.
6. Anemia.
7. Diabetes.
8. History of tobacco use.
PROCEDURES DURING THIS ADMISSION: Percutaneous abdominal drainage and injection of chemotherapy.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old gentleman with history of a small cell lung cancer treated with both chemotherapy and radiation. He had been in stable condition as of late until about one month ago when he started to develop symptoms of increasing shortness of breath. This has been associated with swelling in his lower extremities as well as development of jaundice.
He presented to the emergency department where he was noted to have a right upper lobe infiltrate and a new right pleural effusion. For that, he was admitted for further evaluation and treatment. Also, complains upon admission of decreased appetite and constipation.
HOSPITAL COURSE: After assessment in the emergency department, the patient was admitted and placed on IV fluids. Labs were obtained, and consult was made to the pulmonary specialist regarding the patient’s diagnoses of lung CA and pneumonia. The patient was placed on the community-acquired pneumonia protocol and treated with IV antibiotics. For management of his diabetes, a consult was made to the endocrine specialist, and he was maintained on nutritional therapy, Accu-Chek monitoring, insulin therapy with evaluation of TSH and hemoglobin A1c. A consult was made to the pulmonary specialist regarding his pleural effusion and shortness of breath. After assessment and evaluation, recommendation was for ultrasound-guided thoracentesis, evaluation of the abdomen for ascites, and oxygen to keep saturation greater than 93%.
On MM/DD/YYYY, the patient also underwent evaluation by bilateral venous Doppler of the lower extremities with no evidence of deep vein thrombosis of the right or left leg noted. He also underwent evaluation for dyspnea with a 2-dimensional echocardiogram. This revealed concentric left ventricular hypertrophy present with normal left ventricular systolic function noted. Abnormal diastolic compliance was seen. No pericardial effusion was noted.
The patient underwent ultrasound-guided paracentesis for his diagnosis of ascites and successful paracentesis was done with removal of about 250 mL of bloody ascitic fluid. CT scan of the brain obtained on MM/DD/YYYY revealed no acute intracranial pathology identified. Current scan appears similar to that of previous done almost 10 months ago. Ultrasound of the chest was ordered with regard to pleural effusion. Ultrasound revealed a small right pleural effusion present. Despite removal of fluid, the patient continued to have dyspnea and shortness of breath.
Discussion was made with the patient and his family with regard to his current condition and overall poor prognosis. He was treated in the past with both chemotherapy and radiation and now presents with pleural effusion and ascites with associated jaundice. The patient was made a DNR with full active treatment and was in agreement to single-agent chemotherapy for salvage chemotherapy. The patient was then treated with single-agent irinotecan (CPT-11), but despite treatment, he continued to have jaundice, elevated bilirubin, and progressive metastatic disease to the liver.
Discussion was made with both the patient and his wife with regard to discharge planning and hospice care. It was the wish of the patient that he return to home to be cared for by family and for hospice consult to be obtained. Social work was consulted with regard to arranging hospice care at home. Once these arrangements were completed and necessary equipment obtained, the patient was then discharged to home under the care of hospice. We will continue to monitor him closely while under the care of hospice at home.
