nlbarnes
Expert
Hello - I've been posting several "separately identifiable E/Ms" lately. I'm trying to get an understanding and documentation to give to my employer. This is a new patient being seen for possible cancer. The doctor is billing 99203, 46600, & 11100. The patient was refered & scheduled for possible cancer. Does the guidelines "needs to have seen for another issue in addition to cancer" apply? And if not, why please?
Assessment
1. Imaging of gastrointestinal tract abnormal (793.4) (R93.3)
2. Anal cancer (154.3) (C21.0)
3. Metastasis to lymph nodes (196.9) (C77.9)
Plan
Anal cancer
1. Patient education provided.; Status:Complete; Done: 15Apr2016
90 year old female who has at present a minimally symptomatic highly probable anal cancer, likely anal canal squamous cell carcinoma that has grown out onto the perianal skin. This is clearly not just a perianal cancer. I believe it has metastasized to the left paraaortic nodes and likely also to the chest. This makes it incurable. At 90 years old, she is unlikely to be a candidate for the usual best therapy which is the Nigro protocol chemoradiation.
Her care given the metastases should be palliative and at the moment there is little to palliate. However, it is difficult to predict what approach can give her the best quality time for the longest.
If we knew the distant metastases were going to progress quickly, then it would be best to leave the anus alone. However, the anal cancer is moderate size now but could still technically be mostly excised or at least debulked back to microscopic residual cancer. This would require taking some sphincter muscle but her bowel movement pattern which I don’t think is related to the cancer is once every 2-3 days so even if she needed a Depends for that, once she had it that bm, she would be ok for another 2-3 days which is not too bad as opposed to a patient who has multiple bms per day. She may still maintain continence to formed bms after an excision but it is hard to know. Recovering from such an excision is likely to be painful like a hemorrhoid surgery, and require sitz baths and there will be significantly bloody mucus drainage early on. Ideally even if she is not a candidate for chemotherapy, perhaps if she was radiated postop once I had debulked all the grossly visible disease, that would give her a better likelihood of staying without a tumor recurrence. As I cannot tell how fast the tumor will grow back, if I debulk it, and she has a miserable postop course and it grows back quickly, then it would be better to have left her alone. If I do leave her alone and it grows quickly enough, once it becomes circumferential or even much larger than it is now, it will be hard to surgically debulk and then she could be dealing with worsening pain and obstruction requiring either colostomy or hospice at that point.
Once the pathology is back, I will discuss all this with the patient and her son. I will also get input from oncology and radiation therapy. She may or may not even be a candidate for radiation.
If it is an adenocarcinoma, which I think is much less likely then the options are different.
All of the above was discussed with the patient, her sister, and who I believe is a caretaker and the patient gave her permission to discuss her care with them present.
Overall I am inclined to locally excise this cancer as she has few other medical problems and I am afraid she will get very symptomatic from it prior to dying from anything else, including the distant metastases.
Thank you for allowing me to consult and assist in the care of your patient.
Chief Complaint
positive PET scan in the anus
History of Present Illness
Interpreter present? NA
History:
Seen in consultation at the request of Dr. T for evaluation of possible anal cancer.
The computer medical record was reviewed back to 2004.
90 year old female who had a PET scan 4/8/16 (see below) in follow up for breast cancer and was noted to have FDG avid uptake in a lung mass, paraaortic nodes, and her anus. I am asked to see her for anorectal exam to rule a primary cancer there.
She saw Dr. D gastroenterology 11/24/14 and bms were noted to be normal with some tendency to constipation but with no blood. At this time it was decided she was too elderly by screening guidelines to have further colorectal cancer screening by colonoscopy. Per the records she had a normal colonoscopy 11/1999 except diverticulosis.
Today she states she has some chronic constipation for many years, with recent worsening. The bms are harder and less frequent. Usually they are large. She usually on prune juice and fiber supplements has bms every 2-3 days. If she took nothing she would go a week with no bm. When she has a hard bm, she can have blood on the paper but only one time dripping in the bowl. She has no anal pain with bms unless they are very large and generally no anal pain at all. She denies weight loss. She has some anorexia.
Abdominal pain: some gas pains some days, not worsening chronically
Prolapse that the patient pushes back: no
Prior anal procedures: none
Previous anal surgery: none
Family history of colorectal cancer: no
Continence evaluation: Patient controls gas: yes
Patient controls diarrhea: she could hold the enema she says but the nurse who gave them to her told me she could not.
Patient controls formed bm: yes
She wears a pull up at nite but for urine only, so she doesn't have to get out of bed as she might fall.
Review of Systems
Constitutional, eye, otolaryngeal, cardiovascular, musculoskeletal, skin, neurological and endocrine review of systems are normal except as noted.
Respiratory: cough.
Gastrointestinal: heartburn.
Genitourinary: nocturia x 3, dysuria.
Psychiatric: depression, anxiety.
Hematologic/Lymphatic: easy bruising, anemia.
Active Problems
1. Abdominal pain, periumbilical (789.05) (R10.33)
2. Abnormal blood chemistry (790.6) (R79.9)
3. Anal cancer (154.3) (C21.0)
4. Anal lesion (569.49) (K62.9)
5. Anemia in chronic kidney disease (285.21,585.9) (N18.9,D63.1)
6. Breast cancer (174.9) (C50.919)
· RIGHT BREAST MASTECTOMY 1997//LEFT BREAST MASTECTOMY 7/2012
7. Carcinoma in situ of breast (233.0) (D05.90)
· RIGHT BREAST 1997.... LEFT BREAST 7/2012(MASTECTOMY)
8. Chronic insomnia (780.52) (F51.04)
9. Depression with anxiety (300.4) (F41.8)
10. Dyslipidemia (272.4) (E78.5)
11. Dysphagia (787.20) (R13.10)
12. Elevated alkaline phosphatase level (790.5) (R74.8)
13. Essential hypertension (401.9) (I10)
14. Headache (784.0) (R51)
15. Hypothyroidism (244.9) (E03.9)
16. Imaging of gastrointestinal tract abnormal (793.4) (R93.3)
17. Metastasis to lymph nodes (196.9) (C77.9)
left paraaortic
18. Parkinson's disease (332.0) (G20)
19. Pulmonary nodule seen on imaging study (793.11) (R91.1)
Past Medical History
1. History of Aspiration pneumonia (507.0) (J69.0)
2. History of anxiety disorder (V11.8) (Z86.59)
3. History of gastritis (V12.79) (Z87.19)
4. History of glaucoma (V12.49) (Z86.69)
5. History of irritable bowel syndrome (V12.79) (Z87.19)
6. History of osteoarthritis (V13.4) (Z87.39)
7. History of sciatica (V12.49) (Z86.69)
8. History of Osteoporosis (733.00) (M81.0)
9. History of Pneumonia of right upper lobe due to infectious organism (486) (J18.9)
Surgical History
1. History of Appendectomy Incidental
2. History of Breast Surgery Mastectomy
· right mastectomy 1997, revision with implant 1998, removal of implant 2008.
3. Breast Surgery Reduction Procedure
4. Breast Surgery Removal Of Mammary Implant Material
5. History of Complete Colonoscopy
· 11/99 neg except diverticulosis
6. History of Oophorectomy
· bilat with tah. no cancer. 1970.
7. History of Radical Total Abdominal Hysterectomy
· 1970 no cancer. fibroids.
Family History
Mother
1. Family history of Thyroid cancer
Father
2. Family history of Myocardial infarction
Sister
3. Family history of malignant neoplasm of breast (V16.3) (Z80.3)
Social History
1. Alcohol Use (History)
· one per day
2. Divorced
· former spouse subsequently died.
3. Former smoker (V15.82) (Z87.891)
· quit age 40
4. Lives with relatives
· Lives with her older sister since 1996.
5. One child
· healthy other then vertigo. He was a physician in sacramento and now works in industry
6. Retired
Current Meds
1. Anastrozole 1 MG Oral Tablet; TAKE 1 TABLET DAILY;
Therapy: 08Aug2012 to (Evaluate:01Jul2016) Requested for: 07Jul2015; Last
Rx:07Jul2015 Ordered
2. Azelastine HCl - 0.15 % Nasal Solution; USE 2 SPRAYS IN EACH NOSTRIL TWICE
DAILY;
Therapy: 17Aug2015 to (Evaluate:14Mar2016) Requested for: 17Aug2015; Last
Rx:17Aug2015 Ordered
3. Carbidopa-Levodopa ER 50-200 MG Oral Tablet Extended Release; TAKE 1 TABLET
THREE TIMES A DAY;
Therapy: 13Aug2012 to (Last Rx:03Feb2016) Requested for: 03Feb2016 Ordered
4. Citalopram Hydrobromide 20 MG Oral Tablet; TAKE 2 TABLETS DAILY;
Therapy: 28Apr2009 to (Last Rx:07Mar2016) Requested for: 07Mar2016 Ordered
5. Combigan 0.2-0.5 % Ophthalmic Solution; 1 DROP INTO BOTH EYES TWICE A DAY;
Therapy: 30Jun2010 to Recorded
6. Cyclobenzaprine HCl - 5 MG Oral Tablet; TAKE 1 TABLET BY MOUTH EVERY 6-8HRS AS
NEEDED FOR MUSCLE SPASM;
Therapy: 23Nov2010 to (Evaluate:02Jun2016) Requested for: 04Mar2016; Last
Rx:04Mar2016 Ordered
7. Docusate Sodium 100 MG Oral Capsule; TAKE 1 CAPSULE TWICE DAILY;
Therapy: 27Jul2015 to (Evaluate:25Sep2015) Requested for: 27Jul2015; Last
Rx:27Jul2015 Ordered
8. Levothyroxine Sodium 50 MCG Oral Tablet; Take 1 tablet by mouth daily for thyroid;
Therapy: 29Aug2012 to (Evaluate:07Nov2016) Requested for: 13Nov2015; Last
Rx:13Nov2015 Ordered
9. Metoprolol Succinate ER 50 MG Oral Tablet Extended Release 24 Hour; 2 PO QDAY
(GENERIC FOR TOPROL XL);
Therapy: 18Dec2015 to (Evaluate:28Jan2017) Requested for: 03Feb2016; Last
Rx:03Feb2016 Ordered
10. PrednisoLONE Acetate 1 % Ophthalmic Suspension; INSTILL 1 DROP IN THE LEFT EYE
DAILY;
Therapy: 19Jul2010 to Recorded
11. PriLOSEC OTC 20 MG Oral Tablet Delayed Release; take 1 tablet daily as needed;
Therapy: 29Apr2009 to Recorded
12. ProAir HFA 108 (90 Base) MCG/ACT Inhalation Aerosol Solution; 2 puff q4h prn SOB,
Wheezing or cough;
Therapy: 01Dec2015 to (Evaluate:26Feb2016) Requested for: 10Feb2016; Last
Rx:10Feb2016 Ordered
13. Prolia 60 MG/ML Subcutaneous Solution; INJECT 60 MG Subcutaneous;
Therapy: 20Mar2015- Requested for: 20Mar2015; To Be Done: 20Mar2015; Status:
NEED INFORMATION - Billable Problem Ordered
14. Prolia 60 MG/ML Subcutaneous Solution; Prolia 60 mg SQ today per Torrey;
Therapy: 22Aug2014- Requested for: 22Aug2014; To Be Done: 22Aug2014; Status:
NEED INFORMATION - Billable Problem Ordered
15. Temazepam 15 MG Oral Capsule; Take only one po qhs as needed for insomnia;
Therapy: 11Mar2015 to (Evaluate:28Apr2016) Requested for: 29Mar2016; Last
Rx:29Mar2016 Ordered
16. Vitamin B-12 ER 1000 MCG Oral Tablet Extended Release; TAKE 1 TABLET DAILY AS
DIRECTED;
Therapy: 30Jun2009 to Recorded
17. ZZ-Ketroprofen 10% Lidocaine 5% DMSO 5% Transdermal Gel; 120GM / 30day
supply APPLY 1/8- 1/4 tsp TO BOTH KNEES EVERY Q8H/ PRN /Pain;
Therapy: 31Jul2012 to (Last Rx:31Jul2012) Ordered
Allergies
1. Codeine Derivatives
2. Darvon-N TABS
3. Novocain SOLN
4. Penicillins
Vitals
Recorded: 15Apr2016 01:40PM
Systolic 154
Diastolic 80
Heart Rate 70
Respiration 16
Temperature 97.4 F
Height 5 ft 1 in
Weight 152 lb
BMI Calculated 28.72
BSA Calculated 1.68
Pain Scale 0
Physical Exam
General Condition: WNWD female in NAD
Lungs: clear
Cor: RRR no m
Groins bilaterally without palpable lymphadenopathy
Rectal: Perianal skin with immediately visible on the left side for about 40% of the circumference of the anus a flat hard mass the extends to about 2cm from the anal verge. The mass also extends into the anus on the left side and left posterolateral is nodular in conformation consistent with an invasive malignancy. I used the rigid sigmoidoscope as an anoscope to about 6cm, there was solid formed stool proximally. The mass extends to the level of the about the dentate line. She is mildly tender to exam but not severely so.
Risks, benefits and indications for anal mass biopsy including bleeding, pain, and possible need for further surgery or biopsies explained. The patient understands and consents.
Alcohol prep. 2 ml of 1% xylocaine with epi injected under the external part of the lesion left lateral and using a 15 blade, a small piece of what appeared to be malignant tissue was taken from the surface of the mass. Hemostasis with agno3 stick and pressure till dry. Dry dressing placed.
Results/Data
Imaging:
PET scan 4/8/16 notable for:
IMPRESSION: Mildly positive FDG PET scan in the right upper lobe
spiculated lesion.
Para-aortic lymphadenopathy. Anal uptake - lesion not excluded. Please
correlate clinically for possible additional workup.
FINDINGS: In the chest, mild uptake is present in the right upper lobe
lesion. No specific mediastinal abnormality is identified. In the
abdomen, hypermetabolic left para-aortic nodes are seen, with a reference
node of 13 mm marked. Mild uptake is present within the sigmoid, which
reveals diverticulosis. There is intense activity in the anus, slightly
more than physiologic limits.
Incidentally noted is opacification of the right maxillary sinus.
Test Name Result Flag Reference
WBC 9.2 K/mcL 3.8-11.0
RBC 3.20 M/mcL L 4.0-5.2
HGB 9.6 g/dL L 12.0-16.0
HCT 29.0 % L 36-46
MCV 91 fL 80-100
MCH 30 pg 26-34
MCHC 33 g/dL 31-36
RDW 14.2 % H 10.5-13.5
Platelet Count 333 K/mcL 150-450
PRELIM ABS NEUT CT 7.06 K/mcL 1.8-7.7
Neutrophils 76.6 % H 44-70
Lymphocytes 11.2 % L 25-46
Monocytes 9.2 % 1-12
Eosinophils 2.6 % 0-8
Basophils 0.4 % 0-2
Absolute Neut Ct 7.06 K/mcL 1.8-7.7
Absolute Lymphs 1.03 K/mcL 1.0-5.0
Absolute monos 0.85 K/mcL H 0-0.8
Absolute Eos 0.24 K/mcL 0-0.5
Absolute Baso 0.04 K/mcL 0-0.2
Differential Type Auto
Comprehensive Metabolic Panel (CMPN) 29Mar2016 02:46PM TORREY MD, MELISSA L
***Outpatient***
Test Name Result Flag Reference
Sample status: NON-FASTING
Sodium 134 mmol/L L 136-146
Potassium 4.9 mmol/L 3.5-5.1
Chloride 97 mmol/L L 98-107
Glucose 142 mg/dL H 70-125
Glucose >199 mg/dL meets ADA threshold for diabetes regardless of fasting status*
CO2 28 mmol/L 22-32
BUN 26 mg/dL H 7-21
Creatinine mg/dL 1.16 mg/dL H 0.55-1.02
Anion Gap 9 mmol/L 6-14
Calcium 9.2 mg/dL 8.4-10.3
Albumin 3.4 g/dL 3.3-5.0
AST 18 Units/L 15-37
Protein,Total 6.9 g/dL 6.3-8.2
Bilirubin, Total 0.5 mg/dL 0.1-1.2
ALT 11 Units/L L 13-59
Alk phos 140 Units/L H 38-126
GFR Calc,Non-African 44 mL/mn/1.73m2 L >60
GFR Calc, African 53 mL/mn/1.73m2 L >60
.
An estimate of GFR is calculated from serum creatinine values using the Modification of Diet in Renal Disease (MDRD) Study equation.
.
Chronic Kidney Disease: <60 mL/min/1.73m2
Kidney failure: <15 mL/min/1.73m2
.
Assessment
1. Imaging of gastrointestinal tract abnormal (793.4) (R93.3)
2. Anal cancer (154.3) (C21.0)
3. Metastasis to lymph nodes (196.9) (C77.9)
Plan
Anal cancer
1. Patient education provided.; Status:Complete; Done: 15Apr2016
90 year old female who has at present a minimally symptomatic highly probable anal cancer, likely anal canal squamous cell carcinoma that has grown out onto the perianal skin. This is clearly not just a perianal cancer. I believe it has metastasized to the left paraaortic nodes and likely also to the chest. This makes it incurable. At 90 years old, she is unlikely to be a candidate for the usual best therapy which is the Nigro protocol chemoradiation.
Her care given the metastases should be palliative and at the moment there is little to palliate. However, it is difficult to predict what approach can give her the best quality time for the longest.
If we knew the distant metastases were going to progress quickly, then it would be best to leave the anus alone. However, the anal cancer is moderate size now but could still technically be mostly excised or at least debulked back to microscopic residual cancer. This would require taking some sphincter muscle but her bowel movement pattern which I don’t think is related to the cancer is once every 2-3 days so even if she needed a Depends for that, once she had it that bm, she would be ok for another 2-3 days which is not too bad as opposed to a patient who has multiple bms per day. She may still maintain continence to formed bms after an excision but it is hard to know. Recovering from such an excision is likely to be painful like a hemorrhoid surgery, and require sitz baths and there will be significantly bloody mucus drainage early on. Ideally even if she is not a candidate for chemotherapy, perhaps if she was radiated postop once I had debulked all the grossly visible disease, that would give her a better likelihood of staying without a tumor recurrence. As I cannot tell how fast the tumor will grow back, if I debulk it, and she has a miserable postop course and it grows back quickly, then it would be better to have left her alone. If I do leave her alone and it grows quickly enough, once it becomes circumferential or even much larger than it is now, it will be hard to surgically debulk and then she could be dealing with worsening pain and obstruction requiring either colostomy or hospice at that point.
Once the pathology is back, I will discuss all this with the patient and her son. I will also get input from oncology and radiation therapy. She may or may not even be a candidate for radiation.
If it is an adenocarcinoma, which I think is much less likely then the options are different.
All of the above was discussed with the patient, her sister, and who I believe is a caretaker and the patient gave her permission to discuss her care with them present.
Overall I am inclined to locally excise this cancer as she has few other medical problems and I am afraid she will get very symptomatic from it prior to dying from anything else, including the distant metastases.
Thank you for allowing me to consult and assist in the care of your patient.
Chief Complaint
positive PET scan in the anus
History of Present Illness
Interpreter present? NA
History:
Seen in consultation at the request of Dr. T for evaluation of possible anal cancer.
The computer medical record was reviewed back to 2004.
90 year old female who had a PET scan 4/8/16 (see below) in follow up for breast cancer and was noted to have FDG avid uptake in a lung mass, paraaortic nodes, and her anus. I am asked to see her for anorectal exam to rule a primary cancer there.
She saw Dr. D gastroenterology 11/24/14 and bms were noted to be normal with some tendency to constipation but with no blood. At this time it was decided she was too elderly by screening guidelines to have further colorectal cancer screening by colonoscopy. Per the records she had a normal colonoscopy 11/1999 except diverticulosis.
Today she states she has some chronic constipation for many years, with recent worsening. The bms are harder and less frequent. Usually they are large. She usually on prune juice and fiber supplements has bms every 2-3 days. If she took nothing she would go a week with no bm. When she has a hard bm, she can have blood on the paper but only one time dripping in the bowl. She has no anal pain with bms unless they are very large and generally no anal pain at all. She denies weight loss. She has some anorexia.
Abdominal pain: some gas pains some days, not worsening chronically
Prolapse that the patient pushes back: no
Prior anal procedures: none
Previous anal surgery: none
Family history of colorectal cancer: no
Continence evaluation: Patient controls gas: yes
Patient controls diarrhea: she could hold the enema she says but the nurse who gave them to her told me she could not.
Patient controls formed bm: yes
She wears a pull up at nite but for urine only, so she doesn't have to get out of bed as she might fall.
Review of Systems
Constitutional, eye, otolaryngeal, cardiovascular, musculoskeletal, skin, neurological and endocrine review of systems are normal except as noted.
Respiratory: cough.
Gastrointestinal: heartburn.
Genitourinary: nocturia x 3, dysuria.
Psychiatric: depression, anxiety.
Hematologic/Lymphatic: easy bruising, anemia.
Active Problems
1. Abdominal pain, periumbilical (789.05) (R10.33)
2. Abnormal blood chemistry (790.6) (R79.9)
3. Anal cancer (154.3) (C21.0)
4. Anal lesion (569.49) (K62.9)
5. Anemia in chronic kidney disease (285.21,585.9) (N18.9,D63.1)
6. Breast cancer (174.9) (C50.919)
· RIGHT BREAST MASTECTOMY 1997//LEFT BREAST MASTECTOMY 7/2012
7. Carcinoma in situ of breast (233.0) (D05.90)
· RIGHT BREAST 1997.... LEFT BREAST 7/2012(MASTECTOMY)
8. Chronic insomnia (780.52) (F51.04)
9. Depression with anxiety (300.4) (F41.8)
10. Dyslipidemia (272.4) (E78.5)
11. Dysphagia (787.20) (R13.10)
12. Elevated alkaline phosphatase level (790.5) (R74.8)
13. Essential hypertension (401.9) (I10)
14. Headache (784.0) (R51)
15. Hypothyroidism (244.9) (E03.9)
16. Imaging of gastrointestinal tract abnormal (793.4) (R93.3)
17. Metastasis to lymph nodes (196.9) (C77.9)
left paraaortic
18. Parkinson's disease (332.0) (G20)
19. Pulmonary nodule seen on imaging study (793.11) (R91.1)
Past Medical History
1. History of Aspiration pneumonia (507.0) (J69.0)
2. History of anxiety disorder (V11.8) (Z86.59)
3. History of gastritis (V12.79) (Z87.19)
4. History of glaucoma (V12.49) (Z86.69)
5. History of irritable bowel syndrome (V12.79) (Z87.19)
6. History of osteoarthritis (V13.4) (Z87.39)
7. History of sciatica (V12.49) (Z86.69)
8. History of Osteoporosis (733.00) (M81.0)
9. History of Pneumonia of right upper lobe due to infectious organism (486) (J18.9)
Surgical History
1. History of Appendectomy Incidental
2. History of Breast Surgery Mastectomy
· right mastectomy 1997, revision with implant 1998, removal of implant 2008.
3. Breast Surgery Reduction Procedure
4. Breast Surgery Removal Of Mammary Implant Material
5. History of Complete Colonoscopy
· 11/99 neg except diverticulosis
6. History of Oophorectomy
· bilat with tah. no cancer. 1970.
7. History of Radical Total Abdominal Hysterectomy
· 1970 no cancer. fibroids.
Family History
Mother
1. Family history of Thyroid cancer
Father
2. Family history of Myocardial infarction
Sister
3. Family history of malignant neoplasm of breast (V16.3) (Z80.3)
Social History
1. Alcohol Use (History)
· one per day
2. Divorced
· former spouse subsequently died.
3. Former smoker (V15.82) (Z87.891)
· quit age 40
4. Lives with relatives
· Lives with her older sister since 1996.
5. One child
· healthy other then vertigo. He was a physician in sacramento and now works in industry
6. Retired
Current Meds
1. Anastrozole 1 MG Oral Tablet; TAKE 1 TABLET DAILY;
Therapy: 08Aug2012 to (Evaluate:01Jul2016) Requested for: 07Jul2015; Last
Rx:07Jul2015 Ordered
2. Azelastine HCl - 0.15 % Nasal Solution; USE 2 SPRAYS IN EACH NOSTRIL TWICE
DAILY;
Therapy: 17Aug2015 to (Evaluate:14Mar2016) Requested for: 17Aug2015; Last
Rx:17Aug2015 Ordered
3. Carbidopa-Levodopa ER 50-200 MG Oral Tablet Extended Release; TAKE 1 TABLET
THREE TIMES A DAY;
Therapy: 13Aug2012 to (Last Rx:03Feb2016) Requested for: 03Feb2016 Ordered
4. Citalopram Hydrobromide 20 MG Oral Tablet; TAKE 2 TABLETS DAILY;
Therapy: 28Apr2009 to (Last Rx:07Mar2016) Requested for: 07Mar2016 Ordered
5. Combigan 0.2-0.5 % Ophthalmic Solution; 1 DROP INTO BOTH EYES TWICE A DAY;
Therapy: 30Jun2010 to Recorded
6. Cyclobenzaprine HCl - 5 MG Oral Tablet; TAKE 1 TABLET BY MOUTH EVERY 6-8HRS AS
NEEDED FOR MUSCLE SPASM;
Therapy: 23Nov2010 to (Evaluate:02Jun2016) Requested for: 04Mar2016; Last
Rx:04Mar2016 Ordered
7. Docusate Sodium 100 MG Oral Capsule; TAKE 1 CAPSULE TWICE DAILY;
Therapy: 27Jul2015 to (Evaluate:25Sep2015) Requested for: 27Jul2015; Last
Rx:27Jul2015 Ordered
8. Levothyroxine Sodium 50 MCG Oral Tablet; Take 1 tablet by mouth daily for thyroid;
Therapy: 29Aug2012 to (Evaluate:07Nov2016) Requested for: 13Nov2015; Last
Rx:13Nov2015 Ordered
9. Metoprolol Succinate ER 50 MG Oral Tablet Extended Release 24 Hour; 2 PO QDAY
(GENERIC FOR TOPROL XL);
Therapy: 18Dec2015 to (Evaluate:28Jan2017) Requested for: 03Feb2016; Last
Rx:03Feb2016 Ordered
10. PrednisoLONE Acetate 1 % Ophthalmic Suspension; INSTILL 1 DROP IN THE LEFT EYE
DAILY;
Therapy: 19Jul2010 to Recorded
11. PriLOSEC OTC 20 MG Oral Tablet Delayed Release; take 1 tablet daily as needed;
Therapy: 29Apr2009 to Recorded
12. ProAir HFA 108 (90 Base) MCG/ACT Inhalation Aerosol Solution; 2 puff q4h prn SOB,
Wheezing or cough;
Therapy: 01Dec2015 to (Evaluate:26Feb2016) Requested for: 10Feb2016; Last
Rx:10Feb2016 Ordered
13. Prolia 60 MG/ML Subcutaneous Solution; INJECT 60 MG Subcutaneous;
Therapy: 20Mar2015- Requested for: 20Mar2015; To Be Done: 20Mar2015; Status:
NEED INFORMATION - Billable Problem Ordered
14. Prolia 60 MG/ML Subcutaneous Solution; Prolia 60 mg SQ today per Torrey;
Therapy: 22Aug2014- Requested for: 22Aug2014; To Be Done: 22Aug2014; Status:
NEED INFORMATION - Billable Problem Ordered
15. Temazepam 15 MG Oral Capsule; Take only one po qhs as needed for insomnia;
Therapy: 11Mar2015 to (Evaluate:28Apr2016) Requested for: 29Mar2016; Last
Rx:29Mar2016 Ordered
16. Vitamin B-12 ER 1000 MCG Oral Tablet Extended Release; TAKE 1 TABLET DAILY AS
DIRECTED;
Therapy: 30Jun2009 to Recorded
17. ZZ-Ketroprofen 10% Lidocaine 5% DMSO 5% Transdermal Gel; 120GM / 30day
supply APPLY 1/8- 1/4 tsp TO BOTH KNEES EVERY Q8H/ PRN /Pain;
Therapy: 31Jul2012 to (Last Rx:31Jul2012) Ordered
Allergies
1. Codeine Derivatives
2. Darvon-N TABS
3. Novocain SOLN
4. Penicillins
Vitals
Recorded: 15Apr2016 01:40PM
Systolic 154
Diastolic 80
Heart Rate 70
Respiration 16
Temperature 97.4 F
Height 5 ft 1 in
Weight 152 lb
BMI Calculated 28.72
BSA Calculated 1.68
Pain Scale 0
Physical Exam
General Condition: WNWD female in NAD
Lungs: clear
Cor: RRR no m
Groins bilaterally without palpable lymphadenopathy
Rectal: Perianal skin with immediately visible on the left side for about 40% of the circumference of the anus a flat hard mass the extends to about 2cm from the anal verge. The mass also extends into the anus on the left side and left posterolateral is nodular in conformation consistent with an invasive malignancy. I used the rigid sigmoidoscope as an anoscope to about 6cm, there was solid formed stool proximally. The mass extends to the level of the about the dentate line. She is mildly tender to exam but not severely so.
Risks, benefits and indications for anal mass biopsy including bleeding, pain, and possible need for further surgery or biopsies explained. The patient understands and consents.
Alcohol prep. 2 ml of 1% xylocaine with epi injected under the external part of the lesion left lateral and using a 15 blade, a small piece of what appeared to be malignant tissue was taken from the surface of the mass. Hemostasis with agno3 stick and pressure till dry. Dry dressing placed.
Results/Data
Imaging:
PET scan 4/8/16 notable for:
IMPRESSION: Mildly positive FDG PET scan in the right upper lobe
spiculated lesion.
Para-aortic lymphadenopathy. Anal uptake - lesion not excluded. Please
correlate clinically for possible additional workup.
FINDINGS: In the chest, mild uptake is present in the right upper lobe
lesion. No specific mediastinal abnormality is identified. In the
abdomen, hypermetabolic left para-aortic nodes are seen, with a reference
node of 13 mm marked. Mild uptake is present within the sigmoid, which
reveals diverticulosis. There is intense activity in the anus, slightly
more than physiologic limits.
Incidentally noted is opacification of the right maxillary sinus.
Test Name Result Flag Reference
WBC 9.2 K/mcL 3.8-11.0
RBC 3.20 M/mcL L 4.0-5.2
HGB 9.6 g/dL L 12.0-16.0
HCT 29.0 % L 36-46
MCV 91 fL 80-100
MCH 30 pg 26-34
MCHC 33 g/dL 31-36
RDW 14.2 % H 10.5-13.5
Platelet Count 333 K/mcL 150-450
PRELIM ABS NEUT CT 7.06 K/mcL 1.8-7.7
Neutrophils 76.6 % H 44-70
Lymphocytes 11.2 % L 25-46
Monocytes 9.2 % 1-12
Eosinophils 2.6 % 0-8
Basophils 0.4 % 0-2
Absolute Neut Ct 7.06 K/mcL 1.8-7.7
Absolute Lymphs 1.03 K/mcL 1.0-5.0
Absolute monos 0.85 K/mcL H 0-0.8
Absolute Eos 0.24 K/mcL 0-0.5
Absolute Baso 0.04 K/mcL 0-0.2
Differential Type Auto
Comprehensive Metabolic Panel (CMPN) 29Mar2016 02:46PM TORREY MD, MELISSA L
***Outpatient***
Test Name Result Flag Reference
Sample status: NON-FASTING
Sodium 134 mmol/L L 136-146
Potassium 4.9 mmol/L 3.5-5.1
Chloride 97 mmol/L L 98-107
Glucose 142 mg/dL H 70-125
Glucose >199 mg/dL meets ADA threshold for diabetes regardless of fasting status*
CO2 28 mmol/L 22-32
BUN 26 mg/dL H 7-21
Creatinine mg/dL 1.16 mg/dL H 0.55-1.02
Anion Gap 9 mmol/L 6-14
Calcium 9.2 mg/dL 8.4-10.3
Albumin 3.4 g/dL 3.3-5.0
AST 18 Units/L 15-37
Protein,Total 6.9 g/dL 6.3-8.2
Bilirubin, Total 0.5 mg/dL 0.1-1.2
ALT 11 Units/L L 13-59
Alk phos 140 Units/L H 38-126
GFR Calc,Non-African 44 mL/mn/1.73m2 L >60
GFR Calc, African 53 mL/mn/1.73m2 L >60
.
An estimate of GFR is calculated from serum creatinine values using the Modification of Diet in Renal Disease (MDRD) Study equation.
.
Chronic Kidney Disease: <60 mL/min/1.73m2
Kidney failure: <15 mL/min/1.73m2
.