PART III Documentation Related to Inpatient Care
6. INSTRUCTED REGARDING BASIC NUTRITION/HYDRATION FOR THE TERMINALLY
ILL PATIENT.
DETAILS/COMMENTS: INSTRUCTED TO TRY AND HYDRATE OFTEN
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Copyright © 2019 by F. A. Davis Company. All rights reserved.
Patient: R.C.
The next document is a palliative care consult for an inpatient who has relapsing lymphoma.
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Patient: R.C.
Palliative Care Initial Consult
Patient: R.C. Age: 44 years MRN: 82407 Requesting Provider: Dr. Amini
Reason for Consultation: Goals of care in the setting of relapsed, refractory lymphoma Date of Service: 9/27/20XX
Interpreter: Rebeca, ID # 4452 Chief Complaint: Fatigue History of Present Illness:
R.C. is a delightful 44-year-old man who was admitted on 9/24/20XX with severe constipation. He had not had BM for 8 days. A CT of his chest showed bilateral pleural effusions and a CT of the abdomen showed moderate fecal load with no obstruction. He had marked ascites. He has a history of relapsed and refractory stage IVB diffuse large B-cell lymphomas and was on MERCK checkmate-155; completed C2D1 on 9/18. He is S/P R-CHOP × 6 but he relapsed within 2–3 months of completing R-CHOP. S/P ICE × 3 (March 20XX), S/P HyperCVAD/MTX × 2 (May, June 20XX), and S/Pd Gem/oxaliplatin/rituximab × 1 (July 27, 20XX). He was recently hospitalized from 8/26 to 9/4 for pleural effusions and SVC syndrome, and again from 9/15 to 9/20 for tumor lysis syndrome and bilateral pleural effusions. Palliative medicine was consulted to assist with goals of care.
Social History:
Tobacco: None ETOH use: None Drug use: None From: California Lives with: Wife
Family: Wife has 2 children from a previous relationship. He has no children. Uncles and aunts and many family members nearby
Enjoys: Currently is trying to work on recovery Work: Maintenance
Spiritual/religious background: Catholic, likes to attend Mass when he can Family History:
No history of cancer Past Medical History:
Lymphoma, diffuse large B-cell Lymphoma, non-Hodgkin Pleural effusion
DVTNo known allergies Home Medications:
Acyclovir 400 mg PO bid Allopurinol 300 mg PO daily Bactrim DS 1 tab PO q MWF MiraLax 17 gram PO bid Review of Systems:
Pain: Denies
Dyspnea: Denies; has dry cough
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Copyright © 2019 by F. A. Davis Company. All rights reserved.
Nausea: Denies
Appetite: “Just fine.” He has managed to regain some weight over the last month Bowel/bladder: Was severely constipated but now having BMs
Activity: Ambulatory and independent with ADLs Sleep: Sleeping well
Mood: Denies anxiety or depression. C/O fatigue PHYSICAL EXAMINATION:
Vital Signs:
T 37.7°C (99.9°F), BP 103/70, heart rate 142, respiratory rate 18, SpO2 98% room air.
General: Alert and oriented, no acute distress.
Respiratory: Respirations are nonlabored. Breath sounds are equal. Symmetrical chest wall expansion.
Cardiovascular: Tachycardia, regular rhythm. No edema.
Gastrointestinal: Soft, nontender, minimal abdominal ascites. Normal bowel sounds.
Musculoskeletal: No tenderness, no swelling, no deformity, moves all 4 extremities spontaneously.
Integumentary: Warm, no lesions, no skin breakdown.
Neurological: Alert, oriented. No focal deficits.
Psychiatric: Cooperative. Appropriate mood and affect.
Labs:
CBC
WBC 3.3 RBC 3.03 HGB 8.7 HCT 26.3 MCHC 35.0 MCV 87 Platelet 57 BMP
Sodium 133 Potassium 4.0 Chloride 100
CO2 16
Glucose 54 BUN 14 Creatinine 0.4 Other
Calcium 7.0 Albumin 3.1 Alk Phos 75 AST 80 ALT 25 Bilirubin 1.4 Cardiac Enzymes
Troponin-1 less than 0.02 Radiology Results:
Chest Single-View Adult Portable
Impression: Small bilateral pleural effusions and mild interstitial pulmonary edema have increased when compared to previous film. Lingular and left lower lobe consolidation are unchanged, accounting for differences in lung volumes, which could represent atelectasis or acute air space disease. No other change in the interim since previous study.
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Ultrasound:
US Thoracentesis W/Imag Rt
Findings: Ultrasound guided right thoracentesis requested. Procedure, benefits, and risks were explained to the patient. Consent obtained. An adequate pocket of fluid was identified in the right hemithorax. Skin was prepped and draped in usual sterile fashion. 2% lidocaine was used for superficial anesthesia. Under direct ultrasound guid- ance a 5 French Yueh catheter was introduced and 1,200 mL of serosanguineous fluid was obtained. Technically successful ultrasound guided right thoracentesis. Patient tolerated procedure well without complication and was returned to the ward in stable condition.
US Ven Duplex Upper Extrem Lt
Findings: Left upper-extremity venous Doppler exam with color Doppler imaging and spectral waveform analysis.
Occlusive deep venous thrombosis seen within the left axillary and left brachial veins. Superficial thrombophlebitis left cephalic vein above the elbow and left antecubital vein. Enlarged heterogeneous lymph nodes seen in the left neck measuring 4.8 × 3.2 × 4.4 cm and left axillary region measuring 6.6 × 4.0 × 5.7 cm. Known history of lymphoma. Impression: findings as above. Report called the patient’s nurse at 2:47 pm.
Problem List:
1. Constipation
2. Fatigue, cancer associated
3. Dry cough; likely secondary to malignant pleural effusions, recurrent 4. Relapsed and refractory stage IVB diffuse large B-cell lymphoma Goals of Care:
This patient has a condition that is life limiting. This case involves complex medical decision-making, including utilization of medications that require close monitoring for toxicity, and discussions about the burdens of resusci- tation efforts and life-sustaining measures (code status). Additionally, at least 20 minutes were spent in discussions about advance care planning and goals of care.
Plan: