St. Dav~d Qeo~getow.

a Bo8pital
A Facility o~ St. David's Medica1 Center
2000 scenic D~ive * Georgetow.a, Texas 78626
(512) 943-3000

MBD RZC#t

.ROOKt:
SBX;

ATTBNDING PHYStDekeratry,Dominic R MD
RBPOR'l' TYPJ:;
ECHOCARDIOGRJ\M REPORT

DATE OF STUDY:

V000242422
V.ICU215-1

LOCAT:rO!f;

v.:rcu

PT STATUS:

ADM

ADM DATB:
Dl:S DATB:

IN
1.1./1.7/l.S

1.1./1.9/201.5

PROCEDURE:

2D echocardiogram.
INDICATIONS:
Hypoxia, shortness of breath.

PHYSICIAN:
Dominic Dekeratry, MD

ORDERING

FINDINGS:

MEASUREMENTS:

Left ventricular end systolic dimension

2.3cm. Interventricular septum l..l.cm.
Posterior wall l..l.cm. Calculated left
ventricular ejection fraction 71.%. Left atrial size 2.9cm. Aortic root 3.2cm.
Proximal ascending aorta 3. lcm, Aortic valve peak velocity 1. lm/ sec. LVOT peak
velocity 1.3m/sec. Mitral mean gradient 3. Mitral valve E:A ratio was not
accurately obtained. TR gradient 38nmHg.
This is a technically difficult study. The patient was tachycardic throughout.
The left ventricle is normal size and normal systolic function, actually mildly
hyperdynamic, estimated ejection fraction 65%. No wall motion abnormalities are
seen. LV wall thickness is normal. Left atrial size is normal. Right atrial
size is normal. Right ventricular size and function normal. Bubble study was
performed. This was a positive bubble study. A moderate amount of right
atrial shunting, probably a PPO. :r could not see the atrial septum clearly in
subcostal views. There was prominent cable flow present into the right atrium.
The aortic valve is trileaflet.
It bas thin leaflets with normal excursion, no
stenosis 'or insufficiency. The mitral valve has thin leaflets and normal
excursion and trivial to mild mitral insufficiency, Tricuspid valve shows
trivial to mild tricuspid insufficiency with mild pulmonary hypertension,
estimated RVSP is 43mmHg.
Pulmonic valve shows no stenosis and trace
insufficiency. Tri~al pericardia! effusion is seen around the base of the
inferior lateral wall. Diastolic function is indeterminate. Normal size aortic
root.
PINAL IMPRESSION:

PATIENT

NAME:

BABU,JOSE

ACCOUNT#: VOOOB403827l

Austin Network PCI **LIVE** (PCI: OE Database COCGTH)

Run:

~~/25/lS-07:20

by BASHAM,LYNN S

Page l. of 2

,....------------------~-

-~

~~-~

1. Technically difficult study.

2. Normal left ventricular size with hyperdynamic systolic function, estimated
left ventricular ejection fraction 65-70\.
3. Normal left ventricular wall thickness.
4 . Nm:mal chamber dimensions .
5. Positive bubble study, probably a patent foramen ovale as noted above.
6. Trivial mitral insufficiency and trivial tricuspid insufficiency.
7. Mild pulmonary hypertension, estimated right ventricular systolic pressure
43!flliHg.
B.
Trivial pericardial effusion.
9. Normal sized aortic root.
10. Comparison to prior study from March 3, 2015, there have been no major
changes. Bubble study was not perfo:tmed on the prior study though and there is
no trivial pericardial effusion. Additionally, the patient was not
significantly tachycardic on prior study as on the current study.
Robert F Denyer, DO
DDT:11/19/2015 1756
TDT:ll/19/2015 1816
Trans By: JT /TTS

JOB ID: 2654227

copies To:
Authenticated and Edited by Robert Frederick Denyer DO On 11/20/15 5:34:06 PM

Report #:

1119-0118

Electronically signed by Robert F Denyer, DO on 11/20/15 at 1735

PATIENT NAME: BABU,JOSE

ACCOUNT#: V00084038271

Austin Network PCI **LIVE** (PCI: OE Database COCGTH)

Run: 11/25/15-07:20 by BASHAM,LYNN S

Page 2 of 2

AUSTIN CANCER CENTER

Experienced specialists. Advanced treatment. The standard for compassionate care.

MRN:
PATIENT:
DOS:
DOB:
TOV:
Chief Complaint:

A150448

Doctor:

Benjamin J. Downie, M.D.

BABU,JOSE
11/17/2015
10/29/1983

Follow Up Visit
"Shortness of breath and cough."

HEMATOLOGIC-ONCOLOGIC PROBLEM LIST:

1. Rhabdomyosarcoma of the epididymis, right sided, metastatic, with pulmonary involvement, diagnosed in
the setting of a right-sided testicular mass, prompting testicular ultrasound on 10/24/2014, revealing an
extratesticular mass on the right side with CT imaging of the abdomen and pelvis on 12/03/2014 revealing an
incidental finding of gallbladder sludge but no evidence of metastatic disease with repeat ultrasonography on
12/26/2014 revealing a new heterogeneous extratesticular mass in close proximity to the previous,
communicating with the previously seen smaller mass, prompting right-sided orchiectomy performed on
12/3112014 by Dr. Koushik Shaw, revealing what was initially reported as an epithelioid leiomyosarcoma,
measuring 8.5 em in maximal dimension, grade 3, diffusely involving the peritesticular space with necrosis
involving approximately 50% of the total tumor volume with all margins negative for tumor and no evidence of
LVI noted with subsequent review at M. D. Anderson altering this diagnosis to rhabdomyosarcoma of the
epididymis. PET/CT imaging performed on 03/13/2015 revealed multiple pulmonary metastases with several
foci of markedly increased activity seen in the lungs bilaterally, corresponding to pulmonary nodules seen on
the CT portion ofthe exam with a maximum SUV ofwhich was seen in a lesion of the infrahilar left lower lobe,
measuring 16.4, with a suspicion for small soft tissue metastases in the scrotal raphe, as well as a suspicion for
small metastases in the left prostate, though this could not be confirmed on CT and was not clinically palpable
at the time ofPET/CT imaging by Dr. Koushik Shaw.
- Status post initiation of induction chemotherapy with Cytoxan, doxorubicin, and vincristine on 03/10/2015,
alongside Neulasta growth factor support and dexrazoxane, as cardioprotectant. The patient developed a
neutropeniC fever one week after his first cycle of therapy.
- Status post progression documented on PET/CT imaging at MD Anderson August 2015, prompting transition
to gemcitabine/Taxotere therapy on 08/25/2015.
Status post development of shortness of breath and cough with CT imaging performed on 11117/2015
revealing interval development of a right-sided pleural effusion with right pleural-based metastases and bulky
lymphadenopathy, all of which was new compared to PET/CT imaging having been performed one month prior
on 10/2112015 atM. D. Anderson Cancer Center.

PAST MEDICAL HISTORY:

1.

Seizure disorder, suffered initially in 2011 while driving, prompting initiation of Keppra, which the
patient remains on to this day.
~

RADIATION ONCOLOGY: Terry Boyle, MD I George R. Brown, MD I Stephen L. Brown, MD I Shannon Cox, MD
Paiman Ghafoori, MD I Matthew McCurdy, MD I Douglas J. Rivera, MD I Kirsten A. Warhoe, MD
HEMATOLOGY I MEDICAL ONCOLOGY: Benjamin J. Downie, MD I Allison E. Gorrebeeck, MD
Gerald Hagin, MD I Brian J. Shimkus, MD I Sanjay Yin (Vinjamaram), MD
NEURO ONCOLOGY: Brian Vaillant, MD
SURGEONS: Jane C. Nelson, MD, FACS I Caroline H. Coombs-Skiles, MD, FACS I Sherrie Parker, MD
Phone: Appt. Line 512.505.5500 I Medical Records 512.334.28981 Fax: 512.334.27021

www.AustinCancerCenters.com

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Page 2 of3
PATIENT: BABU, JOSE
2.

DOB: 10/29/1983

MR: A150448

Status post right-sided orchiectomy, as detailed above.

MEDICATIONS: Keppra twice per day.

ALLERGIES: No known.
INTERVAL HISTORY: Mr. Babu presents with shortness of breath and cough that is resulting in total body
fatigue. He is having difficulty eating. We have tried empiric antihistamines and steroids, none of which have
been effective and he underwent CT imaging today revealing a large, right-sided pleural effusion.
FAMILY HISTORY: Negative for known oncologic conditions.

SOCIAL HISTORY: The patient is married and had a daughter born in 2014. He was married in 2012. He
and his wife are from India. The patient works in IT. He denies any tobacco, alcohol, or illicit drug use. He
lives in North Austin with his family.
REVIEW OF SYSTEMS:
GENERAL: See above in the Interval History.
SKIN: No reported skin, hair, nail changes; no reported itching, rashes, sores, lumps, nor moles.
HEAD,EYES, EARS, NOSE and SINUSES: No reported trauma; no reported visual changes, blurriness or
itching; no reported hearing loss, tinnitus, vertigo, earache; no reported rhinorrhea, stuffiness, sneezing, itching,
allergy nor epistaxis.
NECK: No reported swollen neck, mass, nor goiter.
LYMPHATIC:
No reported anterior or posterior cervical, supraclavicular, axillary, nor inguinal
lymphadenopathy.
CHEST: See above in the Interval History.
CARDIAC: See above in the Interval History.
BREAST: No reported masses, lumps I bumps, skin changes, nor discharge.
GI: No reported abdominal pain, nausea, vomiting, diarrhea, constipation, change in stool color or bleeding,
nor jaundice.
GENITAL: No reported discharge, bleeding, nor pain.
URINARY.: No reported change in urinary output, frequency, hesitancy, hematuria, nocturia, nor incontinence.
EXTREMITIES: No reported weakness, pain, nor swelling.
NEUROLOGIC: No reported focal paralysis, change in mental status, seizures, headaches, loss of sensation,
numbness, tingling, tremors, nor vertigo.
PSYCHIATRIC: No reported change in mood, anxiety, nor memory.
HEMATOLOGIC: See above in the Interval History.
PHYSICAL EXAMINATION:
Vital Signs: Weight up 4 pounds to 180 pounds, temperature 98.4, pulse 150, respiratory rate 32, satting 96%,
blood pre~sure 105/70.
GENERAL: The patient is a pleasant 32-year-o1d male in no acute distress.
SKIN: N~ generalized pallor, localized rashes, nor nail bed changes noted. No palpable abnormalities noted.
HEAD: Nohnal size and shape, no trauma noted.
EYES: Pupils equal, round, and reactive to light. No evidence of conjunctival pallor. No scleral icterus.
NOSE/SINUSES: Symmetrical, nontender, normal mucosa without turbinate inflammation. Sinuses nontender
to pa~pation.

Page 3 of3
PATIENT: BABU, JOSE

DOB: 10/29/1983

MR: Al50448

MOUTH/THROAT: Moist mucous membranes. No ulceration noted. Normal dentition. No pharyngeal

erythema.
NECK: Supple. No masses, goiter, tracheal deviation, nor bruit appreciated.
LYMPHATIC: No anterior I posterior cervical, supraclavicular, axillary, nor inguinal lymphadenopathy.
CHEST: Clear to auscultation with adequate air movement bilaterally. No evidence of crackles nor wheezes.
No dullness to percussion. Breathing appears nonlabored.
CARDIAC: Regular rate and rhythm. No murmurs, gallops, nor rubs appreciated.
BREAST: Deferred.
ABDOMINAL: Normal bowel sounds, soft, nontender and nondistended. No masses nor organomegaly
appreciated.
GENITAL-URINARY: Deferred.
EXTREMITIES: No cyanosis, clubbing, nor edema appreciated. Adequate perfusion noted. No muscle atrophy.
NEUROLOGIC: Deferred.
DATA: White count 17,000 with 76% neutrophils, hemoglobin 9.4 g/dL, platelet count 294,000.
IMPRESSION & PLAN: Mr. Babu is a 32-year-old male with metastatic rhabdosarcoma of the epididymis
with pulmonary involvement who has completed three cycles of gemcitabine/Taxotere with PET/CT imaging
performed at Anderson one month ago that revealed a positive therapeutic response. He has developed rapid
progresSion of disease in the form of a malignant pleural effusion and bulky mediastinal lymphadenopathy. He
is obviously symptomatic from his disease. We reviewed the scan findings today confirming progression and
will discontinue his chemotherapy at this time. He is in need of a pulmonary evaluation and pleural-based
intervention. I have referred the patient to Dr. Dekeratry with whom I discussed the case today.

We will see the patient back after pleural-based intervention is complete and the patient is due to be evaluated at
M. D. Anderson Cancer Center on 12/01/2015. We will likely use their recommendations for therapy as we
move forward in this patient's care.

Electronically Approved By: Benjamin J. Downie, M.D. on 11119/2015 4:21:35 PM

D: 11/17/2015 13:54
T: 11/18/2015 06:40
cc: Koushik Shaw, M.D., FAX: 512-973-3036
Natalie Burger, M.D., FAX: 512-451-0977
Dejka Araujo, M.D., FAX: 713-794-1934
Dominic~Dekeratry, M.D., FAX: 512-819-9335

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----r--

--~--

--------

AUSTIN CANCER CENTER

Experienced specialists. Advanced treatment. The standard for compassionate care.

PATIENT: BABU, JOSE

Attending MD: Benjamin J. Downie, M.D.

MR# A150448

DOB: 10/29/1983

Date of Service: 11116/2015

Patient with worsening shortness of breath and cough and will have CT imaging of the chest, high resolution
without contrast, to evaluate for interstitial changes, potentially associated with his chemotherapy treatment.
Steroids have previously been prescribed as detailed and we will call to recommend he take some Zyrtec and
Flonase over-the-counter as he thinks this could be an allergic component.

Electronically Approved By: Benjamin J. Downie, M.D. on 11116/2015 4:40:03 PM

D: 11116/2015 08:38
T: 11116/2015 09:32

RADIATION ONCOLOGY: Terry Boyle, MD I George R. Brown, MD I Stephen L. Brown, MD I Shannon Cox, MD
Paiman Ghafoori, MD I Matthew McCurdy, MD I Douglas J. Rivera, MD I Kirsten A. Warhoe, MD
HEMATOLOGY I MEDICAL ONCOLOGY: Benjamin J. Downie, MD I Allison E. Gorrebeeck, MD
Gerald Hagin, MD I Brian J. Shimkus, MD I Sanjay Yin (Vinjamaram), MD
NEURO ONCOLOGY: Brian Vaillant, MD
SURGEONS: Jane C. Nelson, MD, FACS I Caroline H. Coombs-Skiles, MD, FACS I Sherrie Parker, MD

Phone: Appt. Line 512.505.5500 I Medical Records 512.334.28981 Fax: 512.334.27021 www.AustinCancerCenters.com