Identifying Data
Full Name: LB
MRN: 423733757
Room: ER Dept 7A
Address: Flushing, NY
Date of Birth: 4/21/1957
Date & Time: March 9th, 2021 @ 9:10am
Location: NYP ER Dept Flushing, NY
Religion: N/A
Source of Information: Self
Reliability: Reliable
Mode of Transport: unknown
Chief complaint: nausea and vomiting x 3 weeks
HPI: 63yo covid negative M with Metastatic melanoma, Chronic lymphocytic leukemia (CLL), DM, CAD, UC and stage 3CKD seen in ER due to nausea and vomiting x 3 weeks after having surgery on his nose. Pt has been here since 7pm the day before and unable to keep anything down. Pt states that he think it is due to the anesthesia he received for the surgery. Pt has diffuse jaundice with icteric sclera and severely swollen bilateral submandibular lymph nodes. Pt stated that he cannot keep food down and has been dry heaving for the past few days. Pt went to check up with his primary doctor who told him to come to ER due to this N/V x 3 weeks. Pt had a planned procedure this week, a biopsy of liver so he came early for the N/V. Pt was diagnosed with melanoma in 2017 but just recently had the cancer removed from his nose and his lymph nodes as it had spread. Pt states his stomach pain is a 6/10 and that he also had foot pain and rates that a 5/10. Pts states the the pain in the umbilical region is bad and asked me not to touch him stomach as he nearly jumped out of the bed when the doctor palpated it. Describes the pain as boring and nothing makes it better but it does not radiated anywhere. Pt states that he is dizzy upon standing and when he urinates it is bright orange ever since the surgery. He denies pain anywhere else except his feet and his umbilical region. Pt states that he was told his foot pain is from diabetes. He has been unable to sleep since the melanoma removal surgery and also wakes up sweating at night. Pt denies pain at the swollen lymph nodes and states that they used to be painful but they did something in the surgery that made them numb and he cannot feel them now.
PMH:
Melanoma x 4 years; recently metastasized to lymph nodes x 6 months ago
Chronic lymphocytic leukemia (CLL) x 6 months
CKD stage 3 diagnosed recently in 2020
UC with flare ups in 2010, 2012 and 2014
Diverticulosis x 10 years
CAD, unable to recall how long
DM x 20 years
Childhood immunizations and vaccinations
PSHx:
s/p Excisional surgery for melanoma on nose 2/16/21 hospital
CAD with two stents placed 2007 hospital
transfusions
Medications: all medications taken PO and last taken before hospitalization unless noted otherwise
Clopidogrel 75mg x 1 tab daily ( has not taken since before surgery)
Simvastatin 40mg x 1 tab daily
Ecotrin (aspirin) 325mg x 1 tab daily
Imbruvica 420mg x 1 tab daily ( was stopped due to low WBC)
Valacyclovir 500mg x 1 tab daily
sulfamethoxazole- tmp DS 1 tab Monday, Wednesday and Friday
linzess (Linaclotide) 280mcg capsule once daily
tresiba-insulin 10 units taken SQ once a day (takes at night)
Supplements: all supplements taken PO and last taken before hospitalization unless noted otherwise
Alpha-lipoic acid 300mg x 2 tabs daily
Vitamin D3 25mg (1000IU) x 2 tabs daily
Vitamin C 500mg x 1 tab daily
Oscal 500mg + 200 vit D3 2 tabs daily
Vitamin B12 1000mcg x 1 tab daily
Feosol ferrous sulfate iron 65mg x 1 tab daily
Multivitamin with iron 65mg x 1 tab daily
Allergies:
Allergic to Celebrex ( reaction to medication)
No other known food, environmental, or medication allergies
Family Hx:
Mother: Breast CA in 1994 and 2014, still living
Father: Prostate cancer, died when he was 72
Brother: has covid but otherwise living and healthy
Grandparents
Social History:
Lives with his 95yo mother in a co-op walk up in Flushing NY, lived there since 2006
Occupation: used to work on wall street as a trader; retired 6 years ago; pt stated that he has a lawyer and is filing for compensation for working during 9/11 and getting melanoma
Relationship: single
Travel: has not been traveling
Pets: none
Smoking: used to smoke from age 13-20 but hasn’t in over 45 years
Alcohol: social drinker, “ like a glass of champagne on New years”
Drugs: denies any drug use
Sex: not sexually active
Exercise: used to walk
Diet: can barely eat now but used to have an average diet
Review of systems:
General: Pt with recent weight loss of around 40lb and not been able to eat x 3 week. Pt with general loss of appetite, generalized weakness/fatigue and night sweats.
Skin, hair, nails: Pt has diffuse jaundice and a bruise on each arm from having blood taken or an IV tried to be placed. Pt skin turgor is good. Patient has thin grey hair with spare hair on the head. Freckles noted on the head but no moles. Pt feet examined for ulcers but none seen just dry skin. Pt not diaphoretic at the moment and no lacerations, excoriations or ulcers seem on pt bilateral arms, feet or ankles.
Head: pt states he has a slight headache but does not know what is causing it and has not taken anything for it. Denies vertigo but states he is dizziness when he got up to use the bathroom before we spoke states it is probably due to not being able to eat or drink.
Eyes: Pt has icteric sclera and denies any changes in vision
any pruritis, visual disturbances, photophobia, abnormal lacrimation, glasses
Ear: Pt denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose: Pt nose is wrapped up in nose cast. Pt denies any pain at the moment and is unable to say if there has been discharge.
Mouth/throat: Pt denies sore throat or use of dentures
Bleeding gums, voice changes, mouth ulcers, dental hygiene, sore tongue
Neck: Pt has severely swollen bilateral submandibular lymph node. Denies pain and states they have been numb. Pt is able to move neck side to side but cannot put chin to chest due to severity of swelling of swollen bilateral submandibular lymph nodes.
Breast: Pt denies any breast pain
Nipple discharge or lumps
Pulmonary system: Denies dyspnea, dyspnea on exertion but states he was weak when he walked to bathroom, denies hemoptysis
cough – with/without expectoration, amount, color and consistency of sputum, wheezing, cyanosis, orthopnea (# of pillows and what happens if no pillows) or paroxysmal nocturnal dyspnea (PND)
Cardiovascular system: Pt denies as heart palpitations or chest pain. Bilateral edema noted in ankles with +3. Pt states this is new. Pt denies syncope but does say he feels dizzy when standing.
Gastrointestinal: Pt has diffuse jaundice and states he has been having constipation issues however last BM was early today. Pt has been experiencing N/V x 3 week and states he has not had an appetite after surgery and has not able to keep food down. He has pain in his abdomen which has recently gotten worse. Pt denies any blood when he uses the bathroom even though he has had hemorrhoids in the pas and has diverticulosis and UCt. Pt denies blood in stool or dark looking stool. Pt has not vomiting recently, he states it’s more like dry heaving because there’s nothing in me.
Pyrosis, dysphagia, diarrhea
Genitourinary system: Pt states that his urine has been orange ever since the surgery. States that this might have to do with the dye they injected and his CKD. Denies urinary frequency or urgency, dysuria, incontinence, or flank pain.
Nocturia, oliguria, polyuria, incontinence; awakening in the night
Nervous: Pt states he has slight headache and does feel like he has had loss in strength; and feels weak;Denies seizures, loss of consciousness, change in cognition / mental status / memory
Musculoskeletal system: Pt states that his feet hurt from the diabetes, and described it as pens and needles feeling in his feet however when pen was traced over foot he could tell where the pen was. Pt denies joint pain
deformity or swelling, redness
arthritis – type, duration, migratory or persistent
Peripheral vascular system – Denies coldness or trophic changes
varicose veins, intermittent claudication
Hematological system – States that he had to stop blood thinners before surgery and has 3cm x 3cm deep purple bruises on right and left arms from when IV was tried and blood was taken
Anemia, Blood transfusions, History of DVT/PE
Endocrine system: Pt has been sweating at night he states; but pt denies heat or cold intolerance
Hirtuism, polydipsia , polyphagia
Psychiatric: Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional; states that his doctor told him he is handling everything pretty well. States “ what can I do except try to beat this thing”
Physical
General: Slender male sitting up in bed with sweatpants and a medical gown with diffuse jaundice and severely swollen lymph nodes appears to be in discomfort. Looks older than stated age of 65
Vital signs:
BP: R seated 98/60
L. seated 97/62
R: 16/min, unlabored P: 76, regular O2 96% RA
T: 36.8o 98.24o
Height: 6’1” weight: 140 BMI: 18.5
Skin: cold & dry texture, adequate skin turgor . Diffuse jaundice with two 3cm x 3cm deep purple bruises on right and left arms where IVs or blood work was attempted
Hair: thin grey hair, sparingly distribution on sides with most of head bald with freckles
Nails: no abnormal coloring or markings; clubbing, capillary refill <2 seconds in upper and lower extremities
Head: normocephalic, atraumatic, non tender to palpation throughout head
Nose: unable to be visualized due to nose cast but purple discoloration and dried blood seen around nares that were exposed.
Ears: Symmetrical and appropriate in size. No lesions/masses / trauma on external ears. No tender to palpabtion of pinna or tragus, No tenderness at mastoid process. Unable to visualize tympatic membrane due to impacted sebum bilaterally. Pt states he missed his appointment in which he gets his ears cleaned.
Hearing test: POSITIVE Rinne and weber midline; whisper test
Sinuses – Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Exams missing due to not done yet
Eyes
Cardiovascular – no JVD
Lungs – Clear to auscultation, no use of accessory muscles, no crackles or wheezes ( I did listen to lungs)
Breast –
Psychiatry –
Abdomen –
Genito Urinary –
Rectal –
Musculo Skeletal: able to ambulate on his own without assistance
Neurological – Alert and oriented x 3
Pertinent diagnostic labs
Lymphocytes: 14
WBC: 17.8
Total bilirubin: 117.7
Direct bilirubin: 16.6
Indirect bilirubin: 1.1
ALT: 241
AST: 282
Alk Phos: 787
BUN/cr ratio: 29
Glucose: 235
GFR: 43
Lactate: 2.0
Lipase: 16
Pertinent diagnostic test
- Ultrasound of liver shows distal obstruction of common bile duct ;Pancreases unable to be visualized due to gas
( my differential diagnoses)
Assessment/problem list
# Biliary obstruction secondary to Stage IV Metastatic Melanoma
#2 secondary liver cancer related to Stage IV Metastatic Melanoma
#3 Chronic lymphocytic leukemia (CLL) secondary to Stage IV Metastatic Melanoma
#4 Stage 3 CKD
(possible plans)
Plan
- Liver biopsy planned of 3/11/21
- Discussion of percutaneous transhepatic cholangiogram (PTC) for Biliary obstruction secondary to Stage IV Metastatic Melanoma
- Discuss palliative care
Summary of my HPI
- I did not bring ROS questions and it shows, I went off of my memory and did more of a focused HPI when I should practice doing a full, broad one
- This was a good lesson to see what information I did not yet
- I enjoyed discussing this case with the resident and learning about direct vs. indirect bilirubin
