DIAGNOSES:
1. Breast cancer, right, stage 1.
2. Metastatic breast cancer, biopsy confirmed MM/DD/YY (ER positive, PR negative, HER2 negative).
3. Cellulitis, right lower abdomen, requiring hospitalization on MM/DD/YY.
TREATMENT:
1. Adriamycin and Cytoxan followed by weekly Taxotere, complete MM/DD/YYYY.
2. Taxotere 35 mg/meter squared weekly, initiated MM/DD/YYYY (3 cycles complete, truncated early secondary to intolerable side effects).
3. Currently Xeloda 2000 mg/meter squared p.o. b.i.d., 7 days on, 7 days, off every 2 weeks, initiated MM/DD/YYYY (4 cycles complete).
4. Evaluation/antibacterials, antifungals, antivirals with no localizing source.
The patient is a (XX)-year-old female with a history of metastatic breast cancer who presents today in followup. She was hospitalized on MM/DD/YY with cellulitis on her abdominal wall. Evaluation did not reveal a source of infection; however, the patient was given antibiotics, antifungals, and antivirals and has subsequently improved. She was discharged on MM/DD/YY. There was some question as to potential reaction to Xeloda, which was stopped 1 day early with her last cycle.
On 14-point review of systems today, the patient reports continued fatigue, slowing improving since hospitalization. Numbness and tingling in her upper and lower extremities is stable and unchanged. Nausea and vomiting; in fact, she had 1 emesis this morning while in the office waiting to be seen, indigestion and heartburn, new low back pain, as well as left hip pain that does radiate down her leg. It is not associated with increased paresthesias; however, she has initiated OxyContin 10 mg b.i.d. and does take 1 oxycodone for breakthrough approximately every other day. She does have shortness of breath with exertion, which is improving since hospitalization; however, remainder of review of systems without pertinent positives.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 176 pounds, stable. Blood pressure 122/78, pulse 74, respirations 20, temperature 98.6.
GENERAL: Alert and oriented x3, pleasant female in no acute distress, speaking in complete sentences without difficulty.
HEENT: Hair is short, regrowing. Pupils are equal, round, reactive to light. Sclerae anicteric. Oropharynx clear.
NECK: Supple.
LYMPHATICS: No cervical, axillary or inguinal lymphadenopathy.
LUNGS: Clear bilaterally to auscultation.
CARDIOVASCULAR: Regular rate and rhythm without murmur.
ABDOMEN: Soft, nontender, nondistended. Bowel sounds active x4 quadrants. No organomegaly. Right lower quadrant reddened area is marked with what appears to be decreasing of erythema and healing wound. Area is nonindurated, nondraining, and nontender. Does have less than 0.5 cm area to the left of the umbilicus, again appears to be healing.
EXTREMITIES: No clubbing, cyanosis or edema. The left lower shin biopsy site is healing with a small scabbed area. No induration or drainage.
NEUROLOGIC: Grossly nonfocal.
LABORATORY STUDIES: Laboratory studies from MM/DD/YY: WBCs 7.4, hemoglobin 11.8, hematocrit 37.4, platelet count 258,000. ANC 3.5. Total bilirubin 0.3, alkaline phosphatase 94, AST 22, ALT 6, LDH 492. Sodium 142, potassium 4.5. BUN 14, creatinine 1.01. CA15-3 is pending.
OTHER STUDIES: CT of the head without contrast from MM/DD/YY showed no intracranial abnormality. Small dense area of sclerosis occupies the left skull; could represent either sclerotic metastases or simply a bone island.
Transesophageal echocardiogram reveals ejection fraction of 55-60%, mild mitral and tricuspid regurgitation. No evidence of acute infectious endocarditis.
CT of abdomen and pelvis without contrast reveals hepatic metastases are only subtly seen on this unenhanced CT. Comparison with prior examination for size changes was not possible because of difficulty in visualizing the lesion margins on current exam without contrast. Right lower abdominal wall cellulitis with infiltration of the subcutaneous fat down to the abdominal wall. No frank abscess or fluid collection.
Chest x-ray from MM/DD/YY reveals no acute pulmonary disease.
IMPRESSION:
1. Breast cancer, right, initially stage 2 (now metastatic to the liver and bone).
2. Previous tamoxifen.
3. Chemotherapy with Taxotere 35 mg/meter squared, initiated MM/DD/YY.
4. Shingles, currently resolved.
5. Depression/anxiety, stable on Celexa.
6. Currently Xeloda 2000 mg/meter squared in split doses, 7 days on, 7 days off, every 2 weeks.
7. Recent history of abdominal cellulitis.
8. New lower back and left hip pain.
DISCUSSION: We discussed our clinical findings along with the laboratory data and results of the scan with the patient. There was some question whether her recent infection was a reaction to Xeloda; however, this is not obviously clear. Tumor markers have been responding nicely.
The patient continues to heal regarding her infection; although, labs are stable today. Given her new hip pain, we will proceed with bone scan, have patient follow up in 1 week to discuss the results as well at that time a CA15-3 will be available for review. If patient continues to improve, we will plan on reinitiating Xeloda and monitoring carefully. The patient was agreeable with the above plan. The patient does have thrush on her tongue. She was given a prescription for nystatin 100,000 units/mL swish and spit 4 times daily x7 days or until resolved, 1 bottle with 1 refill.
