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.

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CHIEF COMPLAINT: Sickle cell beta plus thalassemia.

INTERVAL HISTORY: The patient returns to our pediatric hematology/oncology clinic for followup. Since the last clinic visit, the family moved. He comes accompanied by his foster mother and foster father. The couple is moving forward with adoption, which will become a reality in March of this year.

The patient is now a (XX)-month-old boy with diagnosis of sickle cell beta plus thalassemia. His hemoglobin electrophoresis back in MM/YYYY showed a hemoglobin S of 47%, hemoglobin F of 32%, hemoglobin A of 17%. The patient has been asymptomatic since his last clinic visit. However, mother says that at times he complains of lower extremity pain, which apparently improves with just massage. He has not been hospitalized for vasoocclusive pain crisis or any other sickle cell disease related complications.

One source of concern for mother at this time is the fact that the patient is an oral breather. He snores at night and has frequent congestion despite his Claritin.

MEDICATIONS:
1. Claritin 5 mg p.o. once a day.
2. Albuterol sulfate HFA 90 mcg inhaler 1-2 inhalations every 4-6 hours as needed for wheezing.
3. Nasonex 50 mcg spray, 2 sprays intranasally every day.

REVIEW OF SYSTEMS:
GENERAL: No fever, weight loss or other constitutional symptoms.
SKIN: No rashes, petechiae, bruising or eczema.
HEENT: No vision or hearing problems. No nasal congestion or epistaxis. No mouth pain or difficulty swallowing.
RESPIRATORY: No cough, congestion or difficulty breathing.
CARDIOVASCULAR: No history of heart disease.
GASTROINTESTINAL: No nausea, vomiting, diarrhea, constipation, melena or hematochezia.
GENITOURINARY: No hematuria or dysuria.
MUSCULOSKELETAL: No joint pain or dactylitis.
NEUROLOGIC: Normal developmental milestones.
HEMATOLOGIC: History of sickle cell beta plus thalassemia.

PHYSICAL EXAMINATION:
GENERAL: The patient is alert, happy, in no distress. He cooperated with me during the exam.
VITAL SIGNS: Temperature 97.8, pulse 144, respirations 24, blood pressure 108/68, weight 13.2 kg (25th percentile), height 89.6 cm (25th percentile), oxygen saturation 100% on room air.
HEENT: Normocephalic. Pupils are equally round and reactive. Extraocular muscles are intact. Conjunctivae are clear. Tympanic membranes are pearly gray. Oropharynx is pink and moist. Tonsils are generous for his age, but there is no exudate. His nares seemed congested. There is oral breathing.
LYMPHATICS: No palpably enlarged nodes in the neck, axillae or groin.
CHEST: Clear to auscultation throughout.
HEART: Regular rate and rhythm without murmurs.
ABDOMEN: Soft and benign without organomegaly or masses.
EXTREMITIES: Warm and well perfused without cyanosis or edema.
NEUROLOGIC: Nonfocal.
SKIN: No paleness, rashes, petechiae or bruising.

IMPRESSION:
1. The patient is a (XX)-month-old boy with sickle cell beta plus thalassemia.
2. Hereditary persistence of hemoglobin F.
3. Seasonal allergies with what appears to be chronic rhinitis and probably inflammation of tonsils and adenoids with obstructed nasal breathing.

PLAN:
1. Today, we recommended to the family to schedule an appointment with Dr. John Doe to discuss the fact that he probably has congested upper airways. He may need further treatment with Flonase and referral to ENT for further evaluation. Dr. John Doe may need to consider the possibility of referring him for a sleep study after evaluation from ENT to determine whether he has impaired sleep secondary to nasal obstruction.
2. Regarding his blood work, at the family’s request, we decided not to proceed with further testing. His H&H recently at well-child care was 11.9. His hemoglobin at well-child was 11.9 a couple of weeks ago.
3. The family has recently moved. We would like to refer him back with either Dr. Jane Doe Delario or Dr. Jeff Doe for ongoing care.
4. At this point, we think it will be reasonable to continue to monitor his reactive airway disease, but I would recommend referral to Pediatric Pulmonology if his condition does not improve.
5. The family knows to call or return if his condition worsens in any way.
6. For his lower extremity pain that appears only intermittently, we have suggested the family to give ibuprofen 100 mg/5 mL, 7.5 mL every 8 hours as needed for pain. If that does not improve and he continues to experience pain, he may benefit from treatment with hydrocodone.
7. The family knows to call or return if his condition worsens in any way.

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