History of Present Illness
Pat is a very pleasant 61-year-old gentleman with medical history as above. At my interview today he does admit to weight loss of 15 pounds over the last 4 to 6 weeks. This is because eating food worsens his symptoms of abdominal pain. The abdominal pain is epigastric. Somewhat diffuse may be more midline. He denies reflux symptoms. He has been taking acid reduction for a decade or more. He denies nausea or vomiting, diarrhea or constipation. The pain can be as severe as 8-9 out of 10 but not quite 10. He takes a regular regimen of ibuprofen and Tylenol every 6 hours keeping the pain below 2 4 out of 10. He did have an episode of double vision lasted 3 days. He saw Dr. Brockbank and the note is in the chart. This resolved and has not returned. He denies motor or sensory change. He denies jaundice, pruritus, fever, drenching sweats.
Plan
1. EGD with indication of abdominal pain, history of reflux on proton pump inhibitor and carcinoma.
2. PET CT scan. Indication presently is unknown primary. It would still be indicated even if this was an upper GI malignancy.
3. Continue with Dr. Staley with management of diabetes and other health problems.
4. With regards to pain control fortunately kidney function liver function look appropriate. He continues with his current regimen and if worsening would favor something such as tramadol or oxycodone. Pending diagnosis may consider palliative care as well.
5. Follow-up pending blood work and inform of results.
6. A lot of these things and communication may need to be done by phone in order to take the next most timely step. We will however have short-term follow-up once we have the results and definitive treatment plan.
7. He knows to call us in interim with worsening pain, symptoms or any other question or concern.
Oncologic history:
1998 developed abdominal cramping and discomfort improved with Tylenol and ibuprofen and a significant history of gastroesophageal reflux. He had progressive weakness and found to be anemic with hematocrit of 28%. EGD performed was negative but colonoscopy revealed cancer of the ascending colon.
March 3, 1999 underwent resection of the terminal ileum and right colon. Pathology showed moderate to poorly differentiated carcinoma with mucin production invading through the muscularis to the adventitial fat. 32 lymph nodes sampled none with metastatic disease. The circumferential distal margins and proximal margins were clear. He was seen by Dr. Brian tutor and assessed to have high risk stage II disease and was treated with 5-fluorouracil daily for 5 days every 4 weeks for a total duration of 6 months. This was complicated with a delay secondary to cholecystitis and ileus.. He was followed regularly by Dr. Tutors team until June 2009.
December 13, 2009 CT abdomen and pelvis showed changes of extensive pancreatitis with extensive retroperitoneal fluid similar to exam prior that same day. Possible developing pseudocyst in the anterior body of the pancreas near the pancreatic head, fatty liver and diverticulosis. He suffered with peritonitis requiring surgery and hospitalization and recovery until 2010.
April 6, 2010 CT scan of abdomen and pelvis showed significant interval decrease in size and the previously noted pseudocyst/fluid collections. Minimal fluid adjacent to the tail of the pancreas anterior to the body of the pancreas and inferior to the duodenum. Fat stranding adjacent to the tail of the pancreas and possible fluid in the left paracolic gutter noted.
April 11, 2019 nuclear medicine parathyroid scan with SPECT showed no abnormal sestamibi uptake within the inferior aspect of the right lobe of the liver which corresponded to the lesion on the previous ultrasound.
September 9, 2021 CT scan abdomen and pelvis because of abdominal pain in the left lower quadrant. * Retroperitoneal and portacaval lymphadenopathy with surrounding fat stranding. An soft tissue deposit versus additional enlarged lymph node is seen within the central mesentery near the greater curvature of the stomach, with multiple tiny satellite lesions. These findings are suggestive of metastasis given known history of colon cancer. * Postoperative change of the right hemicolon. No definite nodular enhancement at the resection site. No appreciable liver mass.
September 10, 2021 saw his primary care provider with persistent abdominal pain and biopsy was ordered.
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