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Dept. of Medical Oncology

Discharge Summary
Patient Details
UHID : APJ1.0001193041 IP No: IP15207
Name: Mrs. SEEMA AGARWAL Age: 33Yr 2Mth 16Days Sex: Female
Address: AGARWAL315-1-15-1-,560,SIDDIMBAR BAZAR,Hyderabad,Andhra Pradesh,India.
Bed Details: Regency Floor II , 9042 , BED No: 9042

Date of admission: 17-Jun-2010 12:29 Date of Discharge: 27-Jun-2010 02:16

Treating Doctors

Primary Consultant : Dr. PRASAD S V S S--Medical Oncology--MBBS,MD

(Paediatrics),DM (Medical Oncology & Haemoncology)
Consultants : Dr. MANISH DUGAR --Rheumatology--MBBS,MD (Internal
Medicine) ,FRACP(Rheumatology),
Dr. PRASAD S V S S--Medical Oncology--MBBS,MD
(Paediatrics),DM (Medical Oncology & Haemoncology),
Dr. S C SAMAL~ Dr K A RAMAKRISHNA--Gastroenterology
Surgeons/Consultants :Dr. PRASAD S V S S--Medical Oncology--MBBS,MD
(Paediatrics),DM (Medical Oncology & Haemoncology)
Anesthesiologists : Dr. SANATH REDDY P--Anaesthesiology--MBBS,MD
(Anaesthesia)

Diagnosis
Disease Type Disease Name
Pd METASTATIC PANCREATIC ADENOCARCINOMA WITH BONY
METASTASIS, DVT AND PULMONARY EMBOLISM.
Pd SEVERE VITAMIN D DEFICIENCY

Surgery/Procedure
Surgery Name Date of Surgery/Procedure
BONE MARROW BIOPSY 22-Jun-2010

Chief Complaint(s) and Present Known Illness

Chief Complaint(s) : Pain in Calves for 6 weeks.
Present Known Illness :Mrs. Seema was admited for evaluation of Venous doppler proven deep vein
thrombosis of both lower limbs and painful nodules over her forearms and left foot.
Patient History
Family History : Mother - breast cancer.

History of Drug Allergy : No Known drug allergies

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Physical Examination
General Examination :

Height : 5 ft Weight : 90.00Kg BP : 120 / 80 mmHg

Pulse : 78 / min Temperature : 99 F Respiration : 20 / min
Pallor : No Cyanosis : No Icterus : No
Clubbing : No Edema : No Lymphadenopathy : No

Systemic Examination:

Head & Neck : NAD CVS : NAD

Central Nervous System : NAD Respiratory : NAD
Genito urinary : NAD Gynaecological : NAD
Gastro Intestinal : No palpable mass abdomen. ENT : NAD
Skin : NAD Eye & Fundus : NAD
Spine & Joints : - Tender nodules right forearm, left Dental : NAD
foot. - Superficial thrombophlebitis
left forearm and elbow. - No breast
mass except a vague lump left
upper quadrant (Fibroadenosis).
Cervical and axillary
Lymphadenopathy.
Others : NAD

Investigation Reports
BIOCHEMISTRY
ALBUMIN - SERUM

ALBUMIN - SERUM 5.0 g/dL

GLOBULIN - SERUM:(Calculated) 5.3 g/dL
ALBUMIN:GLOBULIN - SERUM(RATIO) 0.9
(Calculated)
ALBUMIN - SERUM 3.5 g/dL
ALKALINE PHOSPHATASE - SERUM/PLASMA

ALKALINE PHOSPHATASE - SERUM/PLASMA 251 U/L

ALT(SGPT) - SERUM / PLASMA

ALT(SGPT) - SERUM / PLASMA 50 U/L

ALT(SGPT) - SERUM / PLASMA 50 mg/dL
AST (SGOT) - SERUM

AST (SGOT) - SERUM 44 U/L

BILIRUBIN CONJUGATED (DIRECT) - SERUM

BILIRUBIN CONJUGATED (DIRECT) - SERUM 0.1 mg/dL

BILIRUBIN UNCONJUGATED - 0.5 mg/dL
SERUM(Calculated)

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BILIRUBIN, TOTAL - SERUM

BILIRUBIN, TOTAL - SERUM 0.6 mg/dL

BLOOD SUGAR(FASTING)-(LIFE STYLE-ATFL 2002/IC-ITC)

BLOOD SUGAR(FASTING)-(LIFE STYLE-ATFL 100

2002/IC-ITC)
CA (CANCER ANTIGEN) 125 - SERUM

CA (CANCER ANTIGEN) 125 - SERUM 361 U/mL

CA (CANCER ANTIGEN) 19-9 - SERUM

CA (CANCER ANTIGEN) 19-9 - SERUM 30200 U/mL

CALCIUM - SERUM

CALCIUM - SERUM 9.4 mg/dL

CALCIUM - SERUM 8.7 mg/dL
CARBONDIOXIDE, TOTAL - SERUM/PLASMA

CARBONDIOXIDE, TOTAL - SERUM/PLASMA 26 mmol/L

CEA: CARCINO EMBRYONIC ANTIGEN - SERUM

CEA: CARCINO EMBRYONIC ANTIGEN - 5.19 ng/mL

SERUM
CHLORIDE - SERUM / PLASMA

CHLORIDE - SERUM / PLASMA 94 mmol/L

CHOLESTEROL - SERUM / PLASMA

CHOLESTEROL - SERUM / PLASMA 217 mg/dL

CHOLESTEROL - SERUM / PLASMA 186 mg/dL
CREATININE - SERUM / PLASMA

CREATININE - SERUM / PLASMA 0.9 mg/dL

GGTP: GAMMA GLUTAMYL TRANSPEPTIDASE - SERUM

GGTP: GAMMA GLUTAMYL TRANSPEPTIDASE 74 U/L

- SERUM
HDL CHOLESTEROL - SERUM / PLASMA

HDL CHOLESTEROL - SERUM / PLASMA 41 mg/dL

HDL CHOLESTEROL - SERUM / PLASMA 38 mg/dL
HOMOCYSTEINE - SERUM / PLASMA

HOMOCYSTEINE - SERUM / PLASMA 12.7 µmol/L

PHOSPHORUS, INORGANIC - SERUM

PHOSPHORUS, INORGANIC - SERUM 4.0 mg/dL

POTASSIUM - SERUM / PLASMA

POTASSIUM - SERUM / PLASMA 4.1 mmol/L

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PROTEIN ELECTROPHORESIS - 24 HR URINE

Total Urinary Volume(24 hrs): 2100 mL/day

PROTEIN, TOTAL - 24 HR URINE 42 mg/day
INTERPRETATION: THE ELECTROPHOREGRAM
SHOWED NO BANDS.
Impression SUGGESTIVE OF NORMAL
PATTERN- WITH NO DETECTABLE
LOSS OF PROTEIN FRACTIONS.
PROTEIN ELECTROPHORESIS - SERUM

Albumin Fraction: Lowered.

Alpha-1 Fraction: Raised.
Alpha-2 Fraction: Raised.
Beta-1 Fraction: With In Normal Limits.
Beta-2 Fraction: Raised.
Gamma Fraction: With In Normal Limits.
A/G Ratio: Suppressed.
PROTEIN, TOTAL - SERUM / PLASMA

PROTEIN, TOTAL - SERUM / PLASMA 10.3 g/dL

PROTEIN,TOTAL - SPOT URINE

PROTEIN,TOTAL - SPOT URINE 6 mg/dL

CREATININE - SPOT URINE(Modified 56 mg/dL
Jaffe:Alkaline Picrate)
SODIUM - SERUM / PLASMA

SODIUM - SERUM / PLASMA 134 mmol/L

TRIGLYCERIDES - SERUM

TRIGLYCERIDES - SERUM 132 mg/dL

LDL CHOLESTEROL - SERUM / PLASMA: 150 mg/dL
(Calculated)
TRIGLYCERIDES - SERUM 193 mg/dL
LDL CHOLESTEROL - SERUM / PLASMA: 109 mg/dL
(Calculated)
UREA - SERUM / PLASMA

UREA - SERUM / PLASMA 19 mg/dL

UREA NITROGEN SERUM/PLASMA:(Calculated) 9 mg/dL
VITAMIN B12 -SERUM

VITAMIN B12 - SERUM >2000 pg/mL

VITAMIN D3(25-0H)-SERUM/PLASMA

VITAMIN D3(25-0H)-SERUM/PLASMA <4.0 ng/mL

VITAMIN FOLATE - SERUM

VITAMIN FOLATE - SERUM 11.6 ng/mL

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HAEMATOLOGY
ACTIVATED PARTIAL THROMBOPLASTIN TIME

APTT 28.9 sec.

Control 30
BONE MARROW CORE BIOPSY ONLY

Brief clinical history Multiple osteolytic, lesions with DVT

? Mets/? myeloma/? TB.
Macroscopic Examination: Multiple ,linear brown bits each
measuring 0.5 cms long ,-ETP.
Microscopic description: Trephine core sections showing mostly
marrow clots and tiny trephine cores
showing foci of normo cellular marrow
with normal hemotopoiesis. Rest of the
marrow clot section and foci of
trephine core showing infiltration with
large anaplastic epithelium in clusters,
sheets, and discret cells and some
areas with gland formation.
Conclusion: The BMB is consistent with that of
infiltration with metastatic
adenocarcinoma deposits.
BONE MARROW SMEAR/SLIDE FOR OPINION

Brief clinical history Recently diagnosed C/O DVT ? MM /

? Lymphoma/ ? TB / ? Mets
Blood Smear: Leukocytosis +, with shift to right,
megathrombocytes +, micro
spherocytes +
Bone Marrow Aspiration: Marrow aspirated from left post, iliac
crest
Marrow is sparsely cellular
Megakaryocytes are present, appear
normal
Erythroid : Myeloid ratio is 1.2:1.
Erythropoiesis is normoblastic
Granulopoiesis is relatively diminished
Myelogram showed predominance of
normoblasts and a few discrete,
atypical epithelial cells, clusters with
intracytoplasmic ? mucin vacuoles.
Myelogram : Neutrophils : 18,
Normoblasts : 62, Blasts : 01,
Myelocytes : 08, Metamyelocytes : 04,
Band forms : 03, Abnormal cells : 04
%, Background showed infiltration with
discrete & clusters of atypical
epithelial cells, at areas forming gland
like structures.

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Conclusion: The BMA/BMI cytology is consistent

with that of infiltration with metastatic
adenoarcinoma deposits.
C B C WITH ESR (AUTOMATION + STANDARD METHOD)

Hemoglobin 13.9 g/dl

Haematocrit 43.6 %
RBC COUNT 4.97 Million/ul
MCV 88 fl
MCH 27.9 pg
MCHC 31.9 g/dl
RDW 11.2 %
TLC Count 13.3 10³/mm³
Platelet Count 233 10³/mm³
ERYTHROCYTE SEDIMENTATION RATE (ESR) 38 mm/1st hr
Neutrophils 76 %
Lymphocytes 18 %
Eosinophils 04 %
Monocytes 02 %
Basophils 00 %
RBC: Normocytic & normochromic
WBC: Neutrophilic leukocytosis +,
eosinophilia +
Platelets: Adequate on the smear
ERYTHROCYTE SEDIMENTATION RATE (ESR)

ERYTHROCYTE SEDIMENTATION RATE (ESR) 25 mm/1st hr

PROTHROMBIN TIME

Prothrombin Time (PT): Test 17.6 sec.

Mean Normal Prothrombin Time (MNPT) 13.5 sec.
INR 1.42
Prothrombin Time (PT): Test 34.1 sec.
Mean Normal Prothrombin Time (MNPT) 13.5 sec.
INR 3.37
SCREENING FOR LUPUS ANTI-COAGULANT)(dRVVT)

SCREENING FOR LUPUS ANTI-COAGULANT) Please repeat the test after six weeks.
(dRVVT)
SCREENING FOR LUPUS ANTI-COAGULANT) Positive
(dRVVT)
URINE- BENCE JONES PROTEINS

URINE- BENCE JONES PROTEINS Negative

URINE ROUTINE (CUE)

Specific Gravity 1.010

Colour: Pale-Yellow
Transparency: Clear
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Reaction: Acidic
Protein : Nil
Glucose: Nil
pH 5
Blood: Negative
Ketone Negative
Bile Pigments: Negative
Bile Salts(Hay's Test): Negative
Urobilinogen Normal E.U./dL
Nitrite Negative
WBC/Pus Cells 2-4 /hpf
Tc/Sqc(Transitional/Squamous epithelial cells) 4-6 /hpf
Specific Gravity 1.005
Colour: Pale-Yellow
Transparency: Clear
Reaction: Acidic
Protein : Negative
Glucose: Negative
pH 6.5
Blood: Negative
Ketone Negative
Bile Pigments: Negative
Bile Salts(Hay's Test): Negative
Urobilinogen Normal E.U./dL
Nitrite Negative
WBC/Pus Cells 2-3 /hpf
Tc/Sqc(Transitional/Squamous epithelial cells) 2-3 /hpf
HISTOPATHOLOGY
IHC - PACKAGE - 1 (5 TO 8 ANTIGENS)

ACTH:
AFP
ALK:
AMHCR(p504s)
Alphafetoprotein:
Amyloid AA:
B Catenin
Bcl 2:
Bcl 6:
Brief Clinical History:
C4d:
CD 10:
CD 15:
CD 20:
CD 23:
CD 30:

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CD 31:
CD 34:
CD 3:
CD 45:
CD 5
CD 56:
CD 57:
CD 68:
CD 79a:
CD 99:
CD-117:
CD-138:
CDX2: Negative.
CEA:
CK - HMW:
CK 10
CK 19: Positive.
CK 20: Negative.
CK 5/6:
CK 7 Strong cytoplasmic positive.
CK 8/18 :
CMV:
Calcitonin :
Caldesmon:
Calretinin:
Chromogranin:
Cyclin D1:
Cytokeratin - Pan (AE1/AE3) :
Desmin :
Diagnosis/Comments: The biopsy shows features of a
metastatic poorly differentiated
carcinoma with focal intracytoplasmic
mucin (confirmed on special stain).
The immune profile, positivity for CK7
and CK19 and negativity for the other
markers mentioned above is in favour
of tumour spread from a primary
pancreatico-biliary carcinoma.
E.Cadherin:
EMA:
Estrogen receptor: Negative.
FSH:
GCDFP-15:
GFAP:
GH:
Galectin 3:
Growth Hormone:

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HMWCK
HBME-1:
HMB 45:
Hepatocyte:
Her 2 neu: Score - 0/3 - Negative.
Hormones-Pituitary:
IgA:
Inhibin:
JCBK
Kappa Lc:
LH:
Lamda Lc:
Leucocyte Common Antigen:
MPO
Mib 1 (Ki 67):
Myeloperoxidase:
Myogenin:
NSE:
Neuron Specific Enolase:
P 16:
P 53:
PAX - 5
PLAP:
PSA:
Pancytokeratin:
Progesterone Receptor: Negative.
Prolactin:
Ref No: BMB-188/10.
S-100 Protein:
Smooth Muscle Actin:
Specimen: Bone marrow biopsy (IHC-610-10).
Synaptophysin:
TTF(Thyroid Transcription Factor): Negative.
Tdt:
Thyroglobuin:
Vimentin:
MICROBIOLOGY
ACID FAST STAIN [BODY FLUID]

AFB Smear No AFB seen

AFB CULTURE [ICD FLUID ](Bact Alert 3D)

Smear Findings No AFB seen

COMPLEMENT LEVEL - C3

COMPLEMENT LEVEL - C3/C3c 1.63 g/l

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COMPLEMENT LEVEL C4

COMPLEMENT LEVEL C4 0.426 g/l

C-REACTIVE PROTEIN (CRP)

C-REACTIVE PROTEIN (CRP) 84.4

C-REACTIVE PROTEIN (CRP) 84.4 mg/L
C-REACTIVE PROTEIN (CRP) Positive
C-REACTIVE PROTEIN (CRP) Positive mg/L
Comments : <3 is Negative
C-REACTIVE PROTEIN (CRP) 13.5
C-REACTIVE PROTEIN (CRP) 13.5 mg/L
C-REACTIVE PROTEIN (CRP) Positive
C-REACTIVE PROTEIN (CRP) Positive mg/L
Comments : <3 is Negative
H I V - 1+2 SCREENING(Ag+Ab)

H I V - 1+2 SCREENING(Ag+Ab) Non-Reactive

INTERPRETATION : NEGATIVE
HBsAg

HBsAg NEGATIVE
HBsAg NEGATIVE S/N
IMMUNOGLOBULIN - IgA

IMMUNOGLOBULIN - IgA 3.26 g/L g/l

IMMUNOGLOBULIN - IgG

IMMUNOGLOBULIN - IgG 15.6 g/L g/l

IMMUNOGLOBULIN - IgM

IMMUNOGLOBULIN - IgM 1.53 g/L g/l

PROCALCITONIN SCREENING

Procalcitonin Screening level: 0.08

Procalcitonin Screening level: 0.08 ng/ml
RA FACTOR

RA FACTOR NEGATIVE
RA FACTOR NEGATIVE mg/L
VDRL (QUALITATIVE) - BLOOD

VDRL (QUALITATIVE) - BLOOD Non-Reactive

TRANSPLANTATION IMMUNOLOGY
ANTI B2-GLYCOPROTEIN-1(IgG)

Dilution: 1:200
RESULT: NEGATIVE
Detected levels: 04

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ANTI CARDIOLIPIN Ab IgG

Detected levels: 04
RESULT: NEGATIVE
ANTI CCP (CYCLIC CITRULLINATED PEPTIDE)

Dilution: 1:100
RESULT: NEGATIVE
Detected levels: 01
ANTI NEUTROPHIL CYTOPLASM ANTIBODIES-(ANCA-IgG)

Dilution: 1:10
RESULT: c-ANCA & p-ANCA=NEGATIVE
ANTI NUCLEAR ANTIBODIES-IgG

Dilution: 1:100
RESULT: NEGATIVE
Reaction Pattern: Nil
Suspected Antigen Specificity: None
C T SCAN RADIOLOGY
MDCT SCAN CHEST (WITH CONTRAST)

MDCT sections of chest were studied with contrast.

Bilateral axillary lymphnodes noted.

MEDIASTINUM :

Soft tissue density stranding with nodularity noted in prevascular, aortopulmonary and
precarinal areas.

Peritracheal soft tissue thickening noted.

Vessels appear normal.

Hypodense area in right upper and lower lobe segmental pulmonary arteries with peripheral
contrast flow - suggestive of thrombus/ emboli.

LUNGS :

Soft tissue density area in both lower lobe posterior segment, right middle lobe lateral segment
and lingula with subtle air bronchogram and adjacent fissural and pleural adhesions -
suggestive of consolidation with ? early cavitation.

Bones show lytic areas.

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Impression : 1. Soft tissue density stranding with nodularity noted in prevascular,

aortopulmonary and precarinal areas - mediastinal lymphadenopathy.

2. Hypodense area in right upper and lower lobe segmental pulmonary arteries with peripheral
contrast flow - suggestive of thrombus/ emboli.

3. Soft tissue density area in both lower lobe posterior segment, right middle lobe lateral
segment and lingula with subtle air bronchogram and adjacent fissural and pleural adhesions -
suggestive of consolidation with ? early cavitation.
Rule-out connective tissue disorder.

4. Bones show lytic areas - myeloma.

Correlate clinically and follow up.

COLOUR DOPPLER
VENOUS DOPPLER OF - BOTH LOWER LIMBS AND LEFT UPPER ARM

Suboptimal study.

Spontaneous flow seen in common femoral veins and superficial femoral veins on either sides.

Sluggish flow seen in right lower superficial femoral vein ? Chronic thrombosis with partial
recanalisation.

Popliteal veins flow appear normal on either sides.

Anterior and posterior tibial veins on both sides are either side show sluggish and intermittent
flow.

LEFT UPPER LIMB :

Flow in cephalic veins appear normal.

The basilic vein appears dilated with hypoechoic thrombus upto the levels of axilla.

The superficial veins of the ventral and dorsal aspect of forearm appear non compressible -
suggestive thrombosis.
Impression :

FLUORO RADIOLOGY
FLURO-GUIDED FNAC

Impression :
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RADIOLOGY
100ML CONTRAST(OMINIPAQUE) - C.T.SCAN

Impression :

ULTRASOUND RADIOLOGY
ULTRASOUND - BREAST

High resolution ultrasound of both breasts was performed in axial, radial and sagittal planes.

Skin, areola, nipple and subcutaneous fat on both sides are normal.

Both breasts are predominantly fatty, and do not show any obvious cysts or mass lesions.

Multiple small lymph nodes seen in both axillary regions, measuring < 12 mm each, showing
loss of fatty central hilum - ? inflammatory.
Impression : No obvious breast parenchymal lesions.

Multiple small lymph nodes in both axillary region, measuring < 12 mm each, showing loss of
fatty central hilum - ? inflammatory.

Sugg: Mammography, if clinically indicated.

ULTRASOUND - WHOLE ABDOMEN

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LIVER : Measure ( 146 mm) normal in size . Echotexture is uniform and normal.
No I.H.B.D./ focal lesions.

PORTAL VEIN : Normal in size.

GALL BLADDER : Well distended with normal walls and lumen.

No calculi/pericholecystic fluid.

COMMON BILE DUCT : Normal in size.

PANCREAS : Normal in size and echotexture.

AORTA, IVC and para aortic areas are normal.

SPLEEN : Normal in size ( 92 mm) and echotexture.

KIDNEYS : Both kidneys are normal in site, size and echotexture.

No evidence of calculi/ hydronephrosis.
Right kidney measures : 91 x 42 mm
Left kidney measures : 95 x 47 mm

URINARY BLADDER : Well distended with normal walls.

No evidence of calculi/ growth/ diverticula .

UTERUS : Normal in size and echotexture.

Uterus measures : 82 x 39 x 47 mm
Combined endometrial thickness is 4 mm thickness.

OVARIES : Not visualised

OTHERS : No evidence of any free fluid in P.O.D.

Impression : - Normal study

X RAY
X-RAY BOTH FEMUR AP AND LAT

Bone density and trabecular pattern are normal.

No lytic or sclerotic lesions noted.

No evidence of any fracture seen.

Soft tissues are normal.

Impression : Normal study.

X-RAY DORSOLUMBAR SPINE - AP/LAT

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Bone density is normal.

Alignment of the spine is normal.

Intervertebral disc spaces are normal.

The vertebral bodies, pedicles and neural arches are normal.

No evidence of sclerotic or lytic lesions seen.

No paraspinal soft tissue abnormality is seen.

Impression : Normal study.

X-RAY PELVIS AP

Contrast noted in the sigmoid colon from previous study.

Bone density and trabecular pattern are normal.

No evidence of any lytic or sclerotic lesion noted.

Both S.I. joints and hip joints are normal.

Soft tissues are normal.

Impression : 1. Both hip joints and S.I. joints are normal.

2. Contrast noted in the sigmoid colon from previous study.

X-RAY SKULL LAT

Evidence of calcific opacities in the frontal region adjacent to inner table.

Skull vault and sinsues are normal.

Sell tunica within normal limits.

Meningeal vascular pattern normal.

Irregular calcification noted in the soft tissue neck posteriorly.

Impression : 1) Calcific opacities in the frontal region adjacent to inner table.

2) Irregular calcification noted in the soft tissue neck posteriorly.

ECG
BED SIDE ECG

Ventricular Rate 97 / MIN

QRS 0.09 SEC
QTc 0.44 SEC
Atria-Rate 97 / MIN
Rhythm SR

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Axis +32°
P R Interval 0.15 SEC
P Wave NORMAL
Voltage NORMAL
Q Wave NIL
St-T Changes T III, V1 - V4
Final Impression NON SPECIFIC 'T' WAVE
CHANGES
ECHO LAB
2D-ECHO WITH COLOUR DOPPLER

Echo No. 287

Mitral Valve AML Normal
PML Normal
Aortic Valve Normal
Tricuspid Valve NORMAL
Plum Valve NO PAH
Great Vessel Relationship NORMAL
Left Atrium NORMAL
Inter Atrial Spetum INTACT
Inter Ventricular Spetum
Intact/VSD INTACT
IVS Thickness 0.7 CM
LV Post Wall
Thickness 0.8 CM
Pericardium : Normal
Dimensions :
Aortic Root Diameter(ed) 3.2 CM
LA Dimension(ed) 3.2 CM
RAID (ed) -
RVID (ed) -
LVID (ed) 4.8 CM
LVID (es) 3.3 CM
Left Ventricular Function
LVESVI -
LVEDVI -
%FD 30%
EF 0.59
Doppler Study -

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Final Diagnosis ALL VALVES AND CHAMBERS

NORMAL
NO REGIONAL WALL MOTION
ABNORMALITY
INTACAT SEPTAE
NORMAL LV FUNCTION
NO PERICARDIAL EFFUSION/NO
CLOT
NO MR/AR/PR/TR.
Summary
- Inj. Gemite 2000 mg once daily.
- Inj. Oxaliplatin (Dacotin) 200 mg once daily.
- Inj. Zometa 4 mg.
- I.V fluids.
- Antiemetics.
- Inj. Magnisium Sulphate and Calcium Gluconate with
Chemotherapy.
- Analgesics.
- Inj. Clexane 60 mg Sc.
- Tab. Pantocid.
- Tab. Thyronorm.
- Fentanyl patch 12.5 mcg daily.
Discussion
Mrs. SEEMA AGARWAL, 33 years female was evaluated for her hypercoagulable state. CTPA showed
pulmonary embolism and lytic lesions on thoracic vertebrae. A F-18 PET bone scan confirmed multiple
bone lytic lesions. A whole body FDG PET scan showed increased septate in lymph nodes, left ovary,
skeletal bones and a bulky pancreas. A work up for malignancy was done Ca - 19 - 9 was significantly
elevated and BM biopsy showed adenocarcinoma. Immunohistochemistry showed positively for Ck 7
and Ck 19 suggesting a primary from Pancreatico-biliary system. She was given the 1st cycle of
Palliative Chemotherapy and discharged home. The treatment plan and progrosis has been extensively
discussed with the family.

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Discharge Medication List

Prescription Comments

PANTODAC 40 MG TAB(PANTOPRAZOLE) 1 Tablet 24 Hourly Once daily before breakfast to

Before Breakfast continue till next review

CLEXANE INJ - 60MG/0.6ML(ENOXAPARIN INJ) 1 Pre Filled Twice daily to continue till next
Syringe 12 Hourly Not Applicable to Meals review

DUPHALAC 200 ML SYP(LACTULOSE) 15 Ml 24 Hourly After Once daily at bed time to

dinner continue till next review

BETADINE GARGLE - 100ML(POVIDONE IODINE GARGLE) 1 Ml Imp. Gargle on every feed

24 Hourly Not Applicable to Meals

DUROGESIC 25MG/H PATCHES 1*3S(FENTANYL) 1 Patches 24 1/2 patch - To be changed on

Hourly Not Applicable to Meals every 3rd day

NEUPOGEN 30 MIO (INDIAN)(FILGRASTIM) 1 Pre Filled Syringe Once daily on 27/06/2010 and
24 Hourly Not Applicable to Meals 28/06/2010

DOLO-650MG(PARACETAMOL) 1 Tablet SOS Not Applicable to As and when required if there

Meals is fever / pain ( SOS )

THYRONORM 50MCG TAB(THYROXINE) 1 Tablet 24 Hourly Once daily BBF to continue till
Before Breakfast next review

ZOFER 8 MG TAB(ONDANSETRON) 1 Tablet 8 Hourly Before Thrice daily before food for 2
Meal days

SHELCOL 500MG TAB(ALFACALCIDOL) 1 Tablet 24 Hourly After Once daily at bed time to
Meal continue till further advice.

CALCIROL GRANULES(ALFACALCIDOL) 1 Sachets 24 Hourly Not ( 60.000 thousand units of

Applicable to Meals Vit-D3 )for 6 weeks ( Every
SUNDAYS only)

Condition on Discharge STABLE

Ambulatory YES Vitals Stable Yes

Blood Sugar Yes Surgical Wound Clean Yes

Levels - Controlled
Pain Score Below 4 Yes

Special Instructions
Dietician Advice :
Post Discharge Investigations :

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Diet :HOME COOKED FOOD, BOILED WATER FOR DRINKING.

Follow-up Instructions :CBP, PT, INR ON 1/7/2010.

REVIEW WITH Dr. S.V.S.S PRASAD ON 2/7/2010.

Physical Activity :As tolerated.
Normal Activities can be resumed after :
Review Consultant :

Contact Information :

Dr. PRASAD S V S S

Primary Consultant JrConsultant/Registrar/Resident

In case of bleeding from wound, temperature above 101 degree F, fresh pain and any other concern
please contact Emergency Room Physician, Apollo Hospitals at 040-60601066 for routine appointment
contact the hospital at 040-60601066.
Page 19 of 19