DATE OF CONSULTATION: MM/DD/YYYY
CONSULTANT: John Doe, MD REFERRING PHYSICIAN: Jane Doe, MD REASON FOR CONSULTATION: Anemia and metastatic pancreatic carcinoma. HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who was recently diagnosed with metastatic liver disease. He underwent an evaluation at the hospital in February and underwent a liver biopsy. The liver biopsy was consistent with an infiltrating adenocarcinoma that was possibly of a biliary/pancreatic origin. Following his diagnosis, he was started on Gemzar through Dr. Doe's office. He was admitted last night through the emergency room for uncontrolled sugars. He was recently started on prednisone to improve his appetite. This most likely is the culprit that has resulted in his uncontrolled sugars at present. He does give a history of abdominal discomfort, especially in the left upper and left lower quadrant. His discomfort has improved after starting palliative chemotherapy. The etiology of this discomfort was noted to be due to peritoneal carcinomatosis. He denies having fever, chills, rigors, nausea, vomiting, bright red blood per rectum, melena, change in bowel movements. PAST MEDICAL HISTORY: 1. No known drug allergies. PAST SURGICAL HISTORY: 1. Left inguinal hernia repair. HABITS: He denies smoking, used to drink alcohol. FAMILY HISTORY: Father died of prostate cancer. MEDICATIONS AT HOME: Prednisone, Lanoxin, Zestril, Coumadin, Zoloft, Reglan, Xanax and Megace. REVIEW OF SYSTEMS: He denies having chest pain, palpitations or shortness of breath. He denies having fever, chills or rigors. He denies having cough or wheezing. He denies having abdominal pain, bright red blood per rectum or melena. He denies having loss of consciousness, seizures or weakness. He denies having headache, blurred vision or diplopia. PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly male, lying in bed, in no apparent distress. VITAL SIGNS: Blood pressure 142/70, pulse 90 per minute, respirations 18 per minute, oxygen saturation 96% and temperature 97.4. HEENT: No pallor, no icterus. Extraocular muscles are intact. Pupils are round and reactive to light. Normocephalic and atraumatic. NECK: No JVD, no cervical lymph nodes, no bruits, no thyromegaly. LUNGS: Vesicular breath sounds heard in both lung fields. No rhonchi, no crackles, no rub. HEART: First and second heart sounds heard, irregularly irregular rhythm. No S3, no S4, no murmurs. ABDOMEN: Bowel sounds heard in all four quadrants. Palpable hepatomegaly with an irregular margin. Mild tenderness noted in the left upper and lower quadrant. No obvious masses palpable. NEUROLOGIC: Alert and oriented x3. Cranial nerves II through XII intact. Motor and sensory system grossly intact. No meningeal signs. No cerebellar deficits. EXTREMITIES: No edema. No Homans. No cyanosis. Pulses 2+. LABORATORY AND DIAGNOSTIC DATA: PT 14.7, INR 1.4, and PTT 29.5. WBC 13.8, hemoglobin 11.7, hematocrit 34.2, and platelet count 286,000. Sodium 131, potassium 5.6, chloride 95, CO2 25.7, glucose 272, BUN 43, creatinine 1.5 and calcium 9.8. EKG: Atrial fibrillation with a heart rate of 100.
ASSESSMENT: 1. Metastatic liver disease. The patient is a (XX)-year-old male who was recently admitted to the hospital with significant weight loss associated with abnormal liver function tests. A CAT scan of the abdomen and pelvis noted a large mass in the tail of the pancreas and multiple hypodensities in the liver. He was seen in consultation and was subjected to a CAT scan guided liver biopsy. He was also subjected to tumor markers that included a CEA and a CA19-9. He was noted to have markedly elevated CA19-9 at 2050. His CEA was 4.3 and his alfa-fetoprotein was less than 1.2. The CT-guided liver biopsy noted a high-grade infiltrating adenocarcinoma that was CK-7 and CAM 5.2 positive. The hepar antigen was negative. Based on this immunohistochemical staining, he was noted to have a metastatic pancreatobiliary carcinoma. His staging workup with CAT scan of the chest noted nonspecific mediastinal and axillary lymphadenopathy. The bone scan was essentially negative for metastatic disease. The CAT scan of the pelvis noted an enlarged prostate with questionable inflammatory changes on the dome of the bladder. Based on this evaluation, he was diagnosed with metastatic pancreatobiliary carcinoma and metastatic disease to the peritoneal wall and the dome of the bladder. Following his diagnosis, he was referred to Dr. Doe's office and has been started on palliative chemotherapy with Gemzar. He has been tolerating Gemzar without much adverse effects. He was admitted to the hospital early this morning with uncontrolled blood sugars. The most likely etiology of his uncontrolled blood sugars is prednisone therapy. PLAN: 1. Wean off prednisone. Thank you, Dr. Doe, for allowing me to participate in the care of this interesting patient. I will follow the patient with you. ------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------ |