Here is the note. Thanks to all!
Chief Complaint
The Chief Complaint is: Pt mother has died from pancreatic cancer and father was just diagnosed.
Active Problems
? Family Hx of Unspecified Malignant Neoplasm
? Hypertension (systemic)
1. Family history of pancreatic cancer in both mother and father, greater than 60 years old.
2. Hypertension
3. Obesity, BMI greater than 30
This is a 45-year-old white female who presents today with a significant family history of both her mother and father being diagnosed with pancreatic cancer. They were both diagnosed greater than 60 years old. She has a first cousin who also has pancreatic cancer. There is no family history colorectal cancer nor breast cancer. There is no family history of recurrent pancreatitis. Her father presented with acute pancreatitis almost a year ago. This was presumed to be biliary pancreatitis. However he had ongoing symptoms and ultimately was diagnosed with pancreatic cancer recently. Patient herself denies any unexplained weight loss, abdominal pain, melena, hematochezia. She states she pursues her other health maintenance issues including pelvic exams and mammograms on a regular basis. She has had no previous screens for pancreatic cancer. She denies any history of heart disease. She does exercise on a regular basis.
History of Present Illness
? Medication list reviewed.
Allergies
? Aspirin
? Zoloft
Current Medication
? Hydrochlorothiazide 25 MG TABS, once a day, 0 days, 0 refills, po
Past Medical/Surgical History
Reported:
Medical: No previous hospitalizations.
Surgical / Procedural: Prior surgery gallbladder removal, appendectomy, hysterectomy.
Diagnoses:
No heart disease.
No asthma
No chronic obstructive pulmonary disease.
No diabetes mellitus
Social History
Behavioral: Caffeine use. No tobacco use, not a current smoker, and not chewing tobacco. Smoking status: Former smoker.
Alcohol: Not using alcohol.
Drug Use: Not using drugs and no marijuana by prescription.
Work: Occupation pharmacy tech.
Marital: Currently married.
Number of children are 2.
Family History
No cholelithiasis
No cirrhosis
No chronic liver disease
No colon polyps
No Intestinal Disorders
No colitis
No malignant neoplasm of the large intestine
Paternal:
Malignant neoplasm pancreatic
Gallbladder removed
Maternal:
Malignant neoplasm pancreatic
Heart disease
Gallbladder removed
Diabetes
Review Of Systems
Systemic: Feeling tired (fatigue). No fever and no recent weight change.
Head: No headache.
Cardiovascular: No chest pain or discomfort and no palpitations.
Pulmonary: No shortness of breath. No wheezing.
Gastrointestinal: No dysphagia. Heartburn. No belching. No nausea, no vomiting, no bloating, and no abdominal pain. No jaundice, no flatus, no melena, and no hematochezia. No diarrhea and no constipation. No rectal pain.
Genitourinary: No hematuria and no burning sensation during urination.
Endocrine: Not alternately too hot and too cold. No excessive sweating.
Hematologic: The patient does not have a blood clot and The patient does not have a bleeding disorder.
Neurological: No dizziness.
Psychological: No anxiety, no depression, and no insomnia.
Skin: No rash.
Physical Findings
? Vitals taken 11/24/2014 01:47 pm
BP-Sitting 138/81 mmHg 100 - 120/56 - 80
Pulse Rate-Sitting 86 bpm 50 - 100
Height 60.5 in 59 - 69
Weight 158 lbs 12.8 oz 98 - 183
Body Mass Index 30.5 kg/m2
Body Surface Area 1.70 m2
PHYSICAL EXAMINATION:
GENERAL: Patient is alert and oriented x3.
HEENT: PERRL, EOMI. Sclera clear. No evidence of lid lag. Mouth, throat with no oral lesions. No leucoplakia or thrush.
NECK: Without lymphadenopathy, thyromegaly or JVD.
LUNGS: Clear to auscultation and percussion.
HEART: RRR with no murmurs, rubs, gallops or clicks.
ABDOMEN Soft, nondistended, nontender, no palpable masses.
RECTAL: Deferred.
EXTREMITIES: Without cyanosis, clubbing or edema.
SKIN: Without rash.
NEURO: Grossly nonfocal. Gait grossly normal. Normal mood, affect, and orientation.
Previous Tests
10/14/14
CMP: Sodium 139, potassium 3.7, chloride 102, CO2 24, BUN 13, creatinine 0.8, glucose 89, total protein 7.1, albumin 4.2, calcium 10.9, phosphorus 3.3, uric acid 6.4, alkaline phosphatase 81, ALT is 25, AST 18, total bilirubin 0.6,
Cholesterol 187, triglycerides 149, LDL 97
CBC: WBC 9.6, hemoglobin 14.2, hematocrit 40.6, platelets 309.
TSH: 1.34
Assessment
? Family hx of unspecified malignant neoplasm
1. Significant family history of pancreatic cancer in both mother and father. Having 2 first-degree relatives with pancreatic cancer does put this patient at high risk group for hereditary pancreatic cancer. Unfortunately, no guidelines exist to guide evaluation. However, a reasonable approach is to consider annual CA 19?9 and MR of the pancreas. If either of these tests are abnormal, then proceeding with endoscopic ultrasound may be beneficial. Patient does not have any other risk factors for pancreatic cancer. Common risk factors include history of tobacco abuse, and chronic pancreatitis, neither of which apply to this patient
Therapy
? Clinical summary provided to patient.
Counseling/Education
? Education and counseling
Plan
? Malignant neoplasm, unspecified
Imaging/General: MRI-Abdominal
Lab: LIVER: CA19-9
? Weight loss diet
1. CA 19?9
2. MR of the pancreas.
3. If either above are abnormal, proceed with endoscopic ultrasound of the pancreas.
4. Annual surveillance with CA 19?9 and MR of the pancreas in this patient in high risk for possible hereditary pancreatic cancer.
5. Annual follow-up
