DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Pancreatic cancer.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old lady whom we have been following for metastatic pancreatic cancer. We saw the patient last in the office in August, and we felt that her clinical condition was deteriorating and she was not strong enough for chemotherapy. We ordered a restaging CT of the chest and abdomen and the plan was to follow up with us after the scans to make a decision about whether to continue with further systemic therapy or to be enrolled in hospice.
Over the course of the two weeks since we saw her, she went to see Dr. Jane Doe where she was placed on the macrobiotic diet and was started back on gemcitabine. She immediately developed the same skin blotchiness that she had developed previously and had progressive upper abdominal back pain and came back to the hospital for evaluation.
PAST MEDICAL HISTORY: Positive for hypertension and positive for depression.
MEDICATIONS: As an outpatient are Lipitor, Zetia, Fosamax, lisinopril, Zoloft, Xanax, vitamin B12, Os-Cal, vitamin C, Neurontin, and since she has been in the hospital, she has been started on a morphine infusion at 3 mg an hour and continues on the Duragesic patch at 75 mcg an hour that she had been on.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Tobacco: She does not smoke. Ethanol: She does not drink.
FAMILY HISTORY: Positive for cancer. Her sister has gastric cancer.
REVIEW OF SYSTEMS: GENERAL: The patient's activity level has been declining. Her Karnofsky performance status is still only 40 and precludes her from doing anything outside the house. PULMONARY: No shortness of breath, no cough. CARDIOVASCULAR: The patient has the midline pain that she attributes to gastroesophageal reflux disease. GASTROINTESTINAL: The patient has no constipation or diarrhea. See history of present illness for remainder. RHEUMATOLOGIC: No bone pain or arthritis. DERMATOLOGIC: Skin rash, see history of present illness. NEUROLOGIC: No headaches, no focal neurologic symptoms.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 118/66, pulse 76, respirations 16, and temperature 97.6.
GENERAL: The patient is a well-developed, well-nourished female who is in moderate discomfort from lower abdominal pain, which she now describes as having gone from her epigastrium down to the lower abdomen and is bilateral.
LUNGS: Clear to auscultation and percussion.
HEART: Regular rhythm and rate without murmur, gallop or rub.
ABDOMEN: Mildly tender. She does have hepatomegaly. There is no splenomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
LYMPH NODES: Negative for cervical, supraclavicular or infraclavicular lymphadenopathy.
LABORATORY DATA: CBC: White blood count 6.4, hemoglobin 10.6, platelets of 188,000. Sodium 138, glucose 114, creatinine 0.8, albumin 3.2, globulin 2.9, calcium 8.4, bilirubin 0.5, AST is 40, alkaline phosphatase is 268.
IMPRESSION:
1. Pancreatic cancer.
2. Liver metastases.
3. Hypertension.
4. Abdominal pain secondary to pancreatic cancer, liver metastasis, and constipation.
5. Constipation.
PLAN:
1. PCA pump. Increase the infusion rate to 4 mg an hour and allow the patient to give herself up to 5 mg an hour.
2. If this is not effective after 24 hours, will have Anesthesia assess the patient for possible epidural pump for narcotic infusion.
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Pancreatic cancer.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old lady whom we have been following for metastatic pancreatic cancer. We saw the patient last in the office in August, and we felt that her clinical condition was deteriorating and she was not strong enough for chemotherapy. We ordered a restaging CT of the chest and abdomen and the plan was to follow up with us after the scans to make a decision about whether to continue with further systemic therapy or to be enrolled in hospice.
Over the course of the two weeks since we saw her, she went to see Dr. Jane Doe where she was placed on the macrobiotic diet and was started back on gemcitabine. She immediately developed the same skin blotchiness that she had developed previously and had progressive upper abdominal back pain and came back to the hospital for evaluation.
PAST MEDICAL HISTORY: Positive for hypertension and positive for depression.
MEDICATIONS: As an outpatient are Lipitor, Zetia, Fosamax, lisinopril, Zoloft, Xanax, vitamin B12, Os-Cal, vitamin C, Neurontin, and since she has been in the hospital, she has been started on a morphine infusion at 3 mg an hour and continues on the Duragesic patch at 75 mcg an hour that she had been on.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Tobacco: She does not smoke. Ethanol: She does not drink.
FAMILY HISTORY: Positive for cancer. Her sister has gastric cancer.
REVIEW OF SYSTEMS: GENERAL: The patient's activity level has been declining. Her Karnofsky performance status is still only 40 and precludes her from doing anything outside the house. PULMONARY: No shortness of breath, no cough. CARDIOVASCULAR: The patient has the midline pain that she attributes to gastroesophageal reflux disease. GASTROINTESTINAL: The patient has no constipation or diarrhea. See history of present illness for remainder. RHEUMATOLOGIC: No bone pain or arthritis. DERMATOLOGIC: Skin rash, see history of present illness. NEUROLOGIC: No headaches, no focal neurologic symptoms.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 118/66, pulse 76, respirations 16, and temperature 97.6.
GENERAL: The patient is a well-developed, well-nourished female who is in moderate discomfort from lower abdominal pain, which she now describes as having gone from her epigastrium down to the lower abdomen and is bilateral.
LUNGS: Clear to auscultation and percussion.
HEART: Regular rhythm and rate without murmur, gallop or rub.
ABDOMEN: Mildly tender. She does have hepatomegaly. There is no splenomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
LYMPH NODES: Negative for cervical, supraclavicular or infraclavicular lymphadenopathy.
LABORATORY DATA: CBC: White blood count 6.4, hemoglobin 10.6, platelets of 188,000. Sodium 138, glucose 114, creatinine 0.8, albumin 3.2, globulin 2.9, calcium 8.4, bilirubin 0.5, AST is 40, alkaline phosphatase is 268.
IMPRESSION:
1. Pancreatic cancer.
2. Liver metastases.
3. Hypertension.
4. Abdominal pain secondary to pancreatic cancer, liver metastasis, and constipation.
5. Constipation.
PLAN:
1. PCA pump. Increase the infusion rate to 4 mg an hour and allow the patient to give herself up to 5 mg an hour.
2. If this is not effective after 24 hours, will have Anesthesia assess the patient for possible epidural pump for narcotic infusion.
