MARTIN, DIEHL HAROLD 2033675 09/05/2007 09/05/2007 18:54:17
Patient Name MR# Observation Date Last
Edited Date
Result Type:
Chest PA and Lateral
Reason For Exam:
PNEUMONIA
REPORT OF EXAM::
Increasing ill-defined right lobe consolidation worrisome for
pneumonia along with right effusion. Overall interstitial markings
also appear slightly prominent ? due to lymphangitic carcinomatosis.
Final Report
Interpreted by: Singh, Satinder P.
Title: MD
Signed Date/Time: 09/05/07 18:54
Calcium Serum Calcium 8.3L mg/dL 8.4 -
10.2
Careset CBC Hgb 11.5L g/dL 13.5 - 17.0
Careset CBC RDW 18.2H % 11.0 - 16.0
Careset CBC WBC 7.55 10^3 4.00 - 11.00
Careset CBC MCH 29 pg 27 - 33
Careset CBC Hct 33L % 39 - 50
Careset CBC MPV 7 fL -
Careset CBC RBC 4.01L 10^6/cmm 4.40 -
5.80
Careset CBC MCHC 35 g/dL 32 - 36
Careset CBC MCV 83 fL 80 - 96
Careset CBC Platelet 192.7 10^3 150.0 -
400.0
Diff Neutrophils 79H % 35 - 73
Diff Eosinophils 1 % 0 - 5
Diff Lymphocytes 7L % 15 - 52
Diff Basophils 0 % 0 - 2
Diff Monocytes 12 % 4 - 13
FBP AGAP 6.0L mEq/L 8.0 - 16.0
FBP Creatinine 1.0 mg/dL 0.7 - 1.3
FBP Chloride 106 mEq/L 96 - 108
FBP Glucose 96* mg/dL 70 - 100
FBP Sodium 137 mEq/L 133 - 145
FBP BUN 20H mg/dL 6 - 19
FBP Bicarbonate 25 mEq/L 23 - 29
FBP Potassium 4.7 mEq/L 3.3 - 5.1
Mg Magnesium 2.3H mg/dL 1.7 - 2.2
Phos Phos 3.3 mg/dL 2.7 - 4.5
Print
MARTIN, DIEHL
MR# 000002033675
08/27/2007
Patient Name
Record No.
V
HISTORY OF PRESENT ILLNESS:
Mr. Diehl is a very pleasant 56-year-old gentleman with recurrent
metastatic pancreatic cancer comes for follow up today. He is
doing
fairly well. He does have some shortness of breath, likely
from the
lymphangitic extend disease complicated by chronic bronchitis which has
resulted in some pneumonia as well. He is currently doing
fairly well.
His pain is well controlled. _____ . Because of
disease progression
noted on his last CT scan, we will attempt to get CPT-11 approved for
use in his case.
PHYSICAL EXAMINATION:
On physical exam, I have no new notable findings.
ASSESSMENT AND PLAN:
_____ . We gave him a register for the first resource
program. I also
talked to him about an investigational agent AT 101 and that the nurse
research would talk to him further about this particular trial.
James A. Posey III, M.D.
JAP/ndv/3328
D: 2007-08-27
T: 8/28/07 5:13 AM
DOB: 03/08/1951
preliminarystamp
Job#dsc7516-0827-740
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MARTIN, DIEHL HAROLD 2033675 08/09/2007 08/10/2007 13:19:56
Patient Name MR# Observation Date Last
Edited Date
Result Type:
Metastatic Survey Complete
Reason For Exam:
evak long bone mestatic rec.pancreatic ca
REPORT OF EXAM::
CLINICAL HISTORY: 56-year-old male with pancreatic cancer.
EXAM: Metastatic survey
FINDINGS: No prior examination is available for comparison. No lytic
or blastic lesions are identified within the skull. There is
asymmetric lucency involving the right mandible without definite
cortical destruction, incompletely evaluate it on single view. There
is no fracture within the spine. There are sclerotic lesions
encompassing essentially the entire T6 vertebral body as well as the
T5 and T8 vertebral bodies. No definite lesions identified within
the cervical or lumbar spine. There are multiple sclerotic lesions
within the left ilium, right sacrum and right ilium, the largest in
the left ilium. No femoral or humeral lesions are identified. There
is a right-sided subcutaneous port with catheter tip projecting over
the SVC.
IMPRESSION: Multiple thoracic spine and pelvic sclerotic lesions
compatible with metastatic disease. Questionable radiolucency
involving right mandible near angle. May represent lytic lesion but
other etiologies than metastases including odontogenic cyst are a
consideration. Could also be artifactual.
gw
Final Report
Interpreted by: Rehder, Dirk
Title: MD
Signed Date/Time: 08/10/07 13:19
--------------------------------------------------------------------------------
End of document
MARTIN, DIEHL
MR# 000002033675
08/13/2007
Patient Name
Record No.
Visit Date
Referring MD: Dr. James A. Posey
Reason for Consultation:
Cough and chest congestion
History:
Mr. Martin is a 56 year-old white male referred for an eight-month
history of a productive cough. He reports that he was in his
usual
state of health until mid-December when he developed an upper
respiratory tract infection with productive sputum and was treated with
Azithromycin with some improvement and has had multiple episodes of
flares with increased coughing and sputum production over the past eight
months. The cough is productive of green sputum when it is at
its
worst. Currently, he is between episodes and recently had
good results
with treatment with Levaquin. He denies fever or frank episodes of
pneumonia requiring IV antibiotics or hospitalization. He denies any
shortness of breath, but has progressive deconditioning over the past
three years since his exercise has decreased since being diagnosed three
years ago with pancreatic cancer. He reports that his cough
is worse
with positional changes, especially when lying down at night.
Past Medical and Surgical History:
Pancreatic cancer, status post Whipple procedure, 10/21/04 treated with
Gemzar, oxaliplatin and Tarceva. He currently has stage IV
disease with
recurrence.
Pulmonary embolism, status post IVC filter.
Hypertension
Medicines:
Lisinopril
Protonix
Carafate
Glycolax
Tarceva
Oxaliplatin
Gemzar
Arixtra
Allergies:
No known drug allergies
Procedures:
Whipple procedure in 2004 for pancreatic cancer
Past History:
He has never had the Pneumovax or influenza vaccination.
Personal and Social History:
The patient is a lifetime non-smoker who was exposed to second-hand
smoke in the home as a teenager. He is a non-drinker.
Occupational History:
He is an electrical engineer who works mostly from home currently.
Family History:
Both parents were smokers. His father died from esophageal
cancer and
his mother died from lung cancer, unknown ages.
Review of Systems:
The pulmonary clinic questionnaire was reviewed with the patient,
signed and placed in the patient’s chart. A
ten-point review is
negative except for that noted in the HPI.
Exam:
Blood pressure 138/80, pulse 75, respirations 14, temperature 97.5,
weight 184 lbs. General: The patient is in no acute
distress. HEENT:
The tympanic membranes are clear bilaterally. Neck:
No adenopathy.
Lungs: No increased work of breathing. He has few
expiratory wheezes
bilaterally. Cardiac: Regular rate and rhythm.
Abdomen: He has a
midline abdominal scar. No palpable organomegaly.
Skin: No rash or
skin lesions.
Data:
Percutaneous oxygen saturation is 98% on room air. Pulmonary
function
testing reveals an FVC of 3.60 liters (79%) and FEV1 is 2.30 liters
(72%) with a ratio of 65%. PFTs show mild obstruction based
on his
FEV1. Total lung capacity is 82% and DLCO is 80%.
His chest CT was
reviewed by Dr. Johnson and me, and shows bilateral peribronchial
thickening with possible bronchiectasis.
Impression:
Chronic bronchitis
Stage IV pancreatic cancer with lymphangitic spread
Plan:
Alternate Augmentin 875 mg twice daily and Avelox 400 mg daily when
episodes of productive coughing begin. The patient was given
prescriptions for both with three refills each.
Return to clinic on an as needed basis.
(Dictated by: Dr. Michael Burch)
ATTENDING PHYSICIAN'S STATEMENT:
I have reviewed the note dictated by Dr. Burch. I agree with
his
findings and plan outlined above.
Mr. Martin is a 56 year-old white male who is referred for evaluation
of chronic congestion. The patient has been having a
productive cough
for about 7-8 months. He has episodes where the sputum turns
green and
then responds to antibiotics. He does not have fever.
He has no
history of smoking and no history of lung disease other than the
metastatic pancreatic carcinoma. The patient had a Whipple
procedure
about three years ago and has been on various chemotherapy regimens.
Most recently, his disease has been progressing despite his
chemotherapy.
For the patient’s past history, family history, social
history and
review of systems, please see Dr. Burch’s note.
Physical Exam:
Blood pressure 138/80, pulse 75, respirations 14 and unlabored,
temperature 97.5, weight 184 lbs. General: The
patient is in no acute
distress. HEENT: His throat is benign.
Neck/Lymph Node: Negative for
mass or adenopathy. Lungs: Essentially clear.
Cardiac: Regular rate
and rhythm without murmurs. Abdomen: Non-tender and
non-distended
without masses. Musculoskeletal: Negative for joint
swelling.
Neurologic: The patient is intact.
Data:
Percutaneous oxygen saturation is 98% on room air. His chest
CT scan,
which was done within the past two weeks, shows evidence of lymphangitic
malignancy. Pulmonary function testing shows a forced vital
capacity of
3.62 (79%) and FEV1 is 2.36 (72%) with a ratio of 65%. Total
lung
capacity is 5.32 (82%) and DLCO is 19.6 (80%).
Impression:
1. Chronic bronchitis – The
patient does not meet strict
criteria, but that is really the way he behaves. He has
episodes where
this becomes worse and responds to antibiotics. I think the
main thing
he needs is to have antibiotics on hand to start immediately when he has
a change in pattern of his cough. I do not think there should
not be a
reason not to proceed with other chemotherapy if there is something that
is available for him.
Pancreatic carcinoma – This is being followed by Dr. Posey.
Plan:
We are giving him a prescription for Augmentin 875 mg twice daily and
also a prescription for Avelox 400 mg daily. I asked him to
use one or
the other for seven days when he has an exacerbation. He
should
alternate these.
He can return to clinic here on an as needed basis and he needs to
continue follow up with Dr. Posey.
James E. Johnson, M.D.
JEJ/pdt/3851
D: 2007-08-13
T: 8/14/07 1:09 PM
cc: James A. Posey, MD – Hematology/Oncology, WTI
227
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