Identifying Data:
Full Name: LJ
Address: Manhattan, NY
Date of Birth: xx/xx/1948
Date & Time: 1/24/2022
Source of Information: Self
Reliability: Reliable
Chief Complaint: warm abdomen after paracentesis x 5 days.
History of Present Illness:
73 y/o female, living with her husband in an apartment, ambulating with a rolling walker and is independent in ADLs prior to admission. She has a past medical history of Stage IV breast cancer (bone, liver) on Xeloda and Herceptin, right upper extremity DVT, gastric ulcers, and hypothyroidism. She was referred to ED by her oncologist on 12/10/21 due to SOB and Hgb of 6.6. From 12/10 – 12/28, she was admitted to Weill Cornell Hospital for dyspnea, ascites, and severe symptomatic anemia. In the ED, pt received 1 unit of pRBC, IV pantoprazole, and IV iron supplement. Hgb increased to 8.3 after transfusion. CTAP at the time showed large volume ascites, nodular liver contour, and bilobar hepatic metastases. Therapeutic paracentesis was performed, 6 L of cloudy yellow fluid was removed. Pt reported improved dyspnea after paracentesis. FOBT was positive. RUE doppler at the time showed a stable clot. Apixaban was held off due to a possible upper GI bleed. On 12/22, EGD showed small esophageal varices and multiple non-bleeding gastric ulcers. Hgb was down trended to 7. Pt had been stable throughout her hospital stay, no signs and symptoms of recurrent upper GI bleed were noted. PT/OT is recommended, and the patient was accepted and transferred to Gouverneur on 12/29.
Currently, pt complains of a warm abdomen after paracentesis for 5 days. Pt went for a paracentesis appointment on 1/19. 7 liters of clear yellow fluid were removed. No complication was noted during the procedure. Pt removed the band-aid that night and noticed her entire abdomen was warm to touch. It has not improved nor worsened since then. Pt also reported redness and mild itchiness around the puncture site. The area of redness was initially small; it has become larger and spread to the side of her abdomen over the past 5 days. Pt has not tried any treatments yet. Pt denies having similar events before. Pt denies fever, chills, night sweats, swelling, pain or drainage at the affected site, abdominal pain, and chest discomfort. Denied contact with an allergen.
Past Medical History:
Metastatic breast cancer (ER + HER2+) to bone and liver, 12/2016
Gastric ulcer
Right upper extremity DVT
Hypothyroidism
Past Surgical History:
C section – 1977
Medications:
Xeloda 500 mg PO, BID, for breast cancer. 7 days on, 7 days off
Herceptin infusion, every 3 weeks, for breast cancer. Last infusion on 1/20
Zoledronic acid infusion, every 3 months, for osteoporosis prevention. Last infusion in 10/2021
Levothyroxine 112 mg PO, daily, for hypothyroidism
Pantoprazole 40 mg PO, daily, for gastric ulcer
Spironolactone 25mg PO, daily, for edema
Furosemide 40mg PO, daily, for edema
Calcium tablet 600 -400 mg unite, PO, daily for calcium deficiency
Ondansetron 4mg PO, q8h as needed for nausea
Allergies
NKDA
Denied food and environmental allergies
Family History:
Mother – rectal cancer
Brother – testicular cancer
Social History
LJ is a married woman living with her husband in an elevator apartment. Pt is the main caretaker of her husband, who has cognitive impairment. Pt reports being mostly independent with ADLs and IADLs except for shopping and going to appointments prior to admission. She received help with IADLs from her daughter. She uses a walker for ambulation.
Habits – Drinks a glass of wine (6 oz) occasionally. Denied tobacco and illicit drug use.
Travel – Denies recent travel.
Occupation – Retired airline customer service.
Sexual Hx – Not sexually active. Denies history of sexually transmitted disease.
ADLs – Independent in all ADLs prior to admission. Currently, needs assistance with ambulation, toileting, and bathing.
IADLs – Needs assistance with shopping and going to appointments prior to admission.
Visual Impairment – None
Hearing Impairment – None
Falls in the past year – None
Assistive devices used – Rolling walker
Gait Impairment – Yes. Need two staffs to help with ambulation
Fecal incontinence – None
Cognitive Impairment – None
Depression – None
Home safety issues – None
Social support – Daughter is available to help with pt’s care
Code status – Full code
Review of System:
General – Admitted to decreased appetite and fatigue. Denied recent weight loss or gain, fever, and night sweats
Skin – Redness over the right side of the abdomen. Mild itchiness around the puncture site. Warmth of entire abdomen. Denied moles, change of skin texture, excess dryness or sweating, itchiness.
Head – Denied headache, light-headedness, recent head trauma.
Eyes –Denied visual disturbances, photophobia, redness, discharge, and tearing.
Ears – Denied tinnitus, deafness, pain, discharge, or use of hearing aids.
Nose – Denied discharge, obstruction, epistaxis, loss of smell, itchiness.
Mouth/throat – Denied sore throat, bleeding gum, mouth ulcers, voice change.
Breast – Breast cancer in right breast. Denied pain, and nipple discharge.
Pulmonary system –Denied SOB, sputum, orthopnea, wheezing, hemoptysis, and cyanosis.
Cardiovascular system – Denied chest pain, palpitations, syncope or known heart murmur.
Gastrointestinal system – Admitted to Intermittent melena, nausea and vomiting (once a month). Relived by ondansetron. Denied dysphagia, abdominal pain, constipation, diarrhea, and hemorrhoids.
Genitourinary system – Denied urinary frequency, urgency, oliguria and incontinence.
Menstrual/Obstetrical – G1 P1 (C section). Menarche age 12. Menopause at age 52. Denied abnormal vaginal discharge, itching, or pain.
Nervous system – Denied seizure, weakness, sensory disturbances, and memory change.
Musculoskeletal system – Bilateral lower extremity edema. Denied joint pain, back pain and muscle pain.
Hematological system – Anemia, last transfusion on 1/13. Right axillary lymph node enlargement.
Endocrine system – Admitted to cold intolerance. Denied polydipsia, polyphagia, heat intolerance, goiter, or excessive sweating.
Psychiatric –Denied history of depression, anxiety, suicidal thoughts, hallucination, and obsessive/compulsive disorder.
Physical Examination:
Vitals:
Temp: 97.8 F, oral
BP: 103/63
Pulse: 84, regular
RR: 20/min, unlabored
O2 saturation: 96% room air
Ht: 5 ft
Wt: 161.8
BMI: 31.6
General – Average-built female in a gown, supine in bed. Patient is AAO X3, not in acute distress. Well-nourished and appears stated age.
Skin – Puncture site is clean and dry, with surrounding erythema. Diffused abdominal erythema over right lumbar region, irregular border, warm to palpation, no induration. No jaundice.
Hair – Average quantity and distribution
Nails – Cracked nails (index fingers and right toe). No clubbing, capillary refill <2 seconds on fingers and toes.
Head – Normocephalic, atraumatic, non-tender to palpation throughout
Sinuses – Non-tender to palpation over bilateral frontal, ethmoid and maxillary sinuses
Ears – Symmetrical and appropriate in size. No lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals. TM is pearly white, intact with light reflex. Weber midline/Rinne reveals AC>BC in both ears.
Eyes – PERRLA. EOMs intact with no nystagmus. Lens clear. No conjunctival injection, pallor, or scleral icterus.
Lips – Pink, moist, no cyanosis or lesions.
Mucosa– Pink, well hydrated. No mass, lesions noted.
Palate – Pink; well hydrated. Palate intact with no lesions, masses, scars.
Teeth – Good dentition. No obvious dental caries noted.
Gingivae – Pink, moist. No hyperplasia, masses, lesions, erythema or discharge.
Tongue – Pink, well papillated. No masses, lesions or deviation.
Oropharynx – Well hydrated. No exudate, masses, lesions. Uvula pink, no edema, lesions.
Neck – Trachea midline. No masses, lesions, scars, pulsations noted. No cervical adenopathy noted.
Thyroid – Non-tender. No palpable masses, no thyromegaly.
Chest – Symmetrical, no deformities, no trauma. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout
Lungs– Clear to auscultation bilaterally.
Heart – Regular rate and rhythm. S1 and S2 are distinct with no murmurs. No splitting of S2 or friction rubs appreciated.
Abdomen – Abdomen is distended, symmetrical. Shifting dullness positive. Bowel sounds normoactive in all four quadrants. Non-tender to palpation throughout, no guarding or rebound noted. No CVA tenderness.
Breast – Right breast: 3cm, hard, non-mobile mass at 10:00 close to tail of spence, non-tender to palpation. Hard fixed node in central chain at right axilla, non-tender to palpation.
Left breast: No masses to palpation. No axillary nodes palpable.
Nipples symmetric without discharge or lesions.
Musculoskeletal – Full passive and active range of motion in shoulders, elbows, wrist, hips, knees, and ankles. No soft tissue swelling, erythema, deformities in bilateral upper and lower extremities. Non-tender to palpation. No crepitus noted throughout.
Neurologic – Sensation intact to light touch, deep touch, pain, and vibration in bilateral upper and lower extremities. Strength 5/5 in bilateral upper/lower extremities.
Peripheral Vascular – 2+ pitting edema of bilateral lower extremities. Bilateral upper and lower extremities symmetric in color, size, and temperature. Pulses are 2+ bilaterally in upper extremities. DP and PT pulses nonpalpable.
Labs and Imaging:
Labs from 1/20
- CBC: WBC/Hgb/Hct/Plts = 5.61/9.7/29.5/323
- TSH/T4 = 81.5/1.1
- Glucose – 153 non-fasting
- BUN – 13
- Creatinine – 0.83
- Total Protein – 5.0
- Albumin – 1.8
- ALK PHOS – 113
- AST – 35
- ALT – 9
Ascites fluid studies 12/24/21
- Gram stain – sparse WBCs, no organisms
- Cx – NG
- Albumin: <0.60
- SAAG (serum-ascites albumin gradient) 1.2
- Cytology: no malignant cells, predominantly histiocytes/macrophages
Assessment and Plan:
73 y/o female with a past medical history of Stage IV breast cancer, right upper extremity DVT, and hypothyroidism complains of warm abdomen, abdominal redness, and itchiness around puncture site after paracentesis for 5 days. The puncture site is clean and dry, surrounded by erythema extending to the entire right lumbar quadrant. No induration. Patient denied pain, fever, chills, or puncture site drainage. Patient’s symptoms are likely due to local infection after paracentesis.
DDx:
- Local infection s/p paracentesis
- Hypersensitivity reaction
# Abdominal warmth and erythema – likely due to local infection after paracentesis (1/19)
- No drainage or signs of infection at puncture site
- Vital trends for the past 5 days are WNL
- Lab from 1/20 showed WBC WNL
- Start Bactrim 800/160 mg PO, daily for spontaneous bacterial peritonitis prophylaxis for 7 days.
# Hypothyroidism
- TSH remains elevated with current levothyroxine dose. T4 WNL
- Increase levothyroxine to 175mg daily
- f/u TSH/T4 in 6 weeks
# Gastric ulcers
# Anemia secondary to upper GI bleed
- Pt continues to have intermittent melena
- Last transfusion on 1/12 and 1/13 in oncology office. Hgb improved from 6.6 to 9.7 after 2 units of pRBC
- Continue to hold apixaban
- Increase Pantoprazole 40mg from daily to twice a day
- Add sucralfate 1g, 1 tab PO, TID for GI protection
- f/u blood work with oncologist in 1 week
# Lower extremity edema
# Ascites
# Small esophageal varices
- Likely caused by portal hypertension secondary to known liver metastases
- S/p therapeutic paracentesis (1/19, 7 L of clear yellow fluid removed)
- Continue spironolactone 25mg daily
- Continue furosemide 40mg daily
- Therapeutic paracentesis as needed
# Metastatic breast cancer
- Continue Xeloda 7 days on, 7 days off as recommended by oncologist
- Continue ondansetron as needed for chemo-induced N/V
- Next Herceptin infusion 2/3
- f/u with oncologist
# RUE DVT
- RUE doppler on 12/10 showed stable clot in right internal jugular vein extending to innominate vein, pt currently asymptomatic
- Continue to hold apixaban due to anemia secondary to upper GI bleed
# Dyspnea on exertion – resolved, likely due to abdominal distention
- Symptoms improved after paracentesis
- Therapeutic paracentesis as needed
