Age: 66.0
Sex: M
Vaccine: COVID19-2
Symptoms: Scan with contrast abnormal, Splenomegaly, Vena cava thrombosis
Clinical narrative: Document Type: Hem Onc OP Provider Note   Document Subject: AMB Consult Note   Performed By: MD   Verified By: MD   Encounter Info: Outpatient, 05/12/23 - 05/12/23    * Final Report *        Reason for Consultation   consult  Referral Source   Subjective     I had the pleasure of seeing this patient for abdominal lymphadenopathy.   Diagnosis:  -Abdominal lymphadenopathy  -Unintentional weight loss   HPI:  Mr. is a pleasant 67-year-old male who presented with reduced appetite, lost about 20 pounds 8 weeks without trying.   His CT abdomen and pelvis with IV contrast on 5/5/2023 showed extensive abdominal lymphadenopathy; enlarged retroperitoneal mass surrounding the abdominal aorta measured 14 cm in width and another large mass in the right upper quadrant of the abdomen measured 21 cm in width.  Splenomegaly, mass effect on the infrahepatic IVC with apparent thrombosis of the inferior aspect of the IVC and the common iliac veins was noted.   Subjective:  The patient felt all right today, I reviewed his test results.  His CT scan was as mentioned above; on 5/3/2023, hemoglobin was low at 11.4 and MCV low normal at 81.  WBC was 3.9, platelet count low normal at 152.  Liver panel was in the normal range.   Chronic problem list, procedure/surgical history, allergies, medications, social and family history:  These were reviewed.  Chronic problem list:  GERD, short Barrett's esophagus.  He is on pantoprazole.  Social history:  He is married who used to work at the Hospital.  The patient also has retired now, no history of smoking, alcohol or drug abuse.  Family history:  Father died of lung disease at age 83, he used to smoke cigarettes.  History of prostate cancer in grandfather in his 80s.  Review of Systems     Constitutional: Poor Appetite, Unintended weight loss  Eyes: Glasses  Gastrointestinal: Diarrhea  05/12/23 09:28:00          Result Name   Value   Comment            Systolic Blood Pressure   107 mmHg                Diastolic Blood Pressure   65 mmHg                Pain Assessment Method   Self-Report                Pain Scale Used   0 - 10 Numeric Rating Scale                Pain Score Global   0                Fall History (Past Year)   No Fall Documented                Little Interest - Pleasure in Activities   Not at All                Feeling Down, Depressed, Hopeless   Not at all                Initial Depression Screen Score   0                 The rest of the review was negative. Physical Exam/Objective  Vitals & Measurements most recent  T: 36.6 °C (Temporal Artery)  BP: 107/65  HR: 95 (Peripheral)  SpO2: 97%  Oxygen Therapy: Room air  WT: 90.90 kg (WFC)  BMI: 27.2  BSA Measured: 2.15 (m2)  HT: 182.9 cm            General: Alert, No acutedistress.         Eye:  Extraocular movements are intact, Normal conjunctiva.         HEENT:  Normocephalic, normalhearing        Neck:  Supple, Non-tender, No thyromegaly.         Cardiovascular: S1 S2 normal, regular rhythm, No murmur.         Respiratory: Respirations are  non-labored,  Lungs are clear to auscultation, Breath sounds are equal.        Lymphatics:  no palpable lymph nodes, no axillary tenderness.         Integumentary:  Intact, No pallor.         Neurologic:  Alert & Oriented x 3, no cognitive impairment,  No focal defects       Psychiatric:  Cooperative, Appropriate mood & affect.         Gastrointestinal:  Non-distended, Non-tender, bilateral upper quadrant dullness, external genitalia normal.      Musculoskeletal:  No swelling, Normal gait.         Assessment/Plan       1. Abdominal lymphadenopathy   R59.0  Clinically this is concerning for lymphoma, a CT-guided biopsy has been requested.   2. Unintentional weight loss   R63.4  The patient has early satiety and reduced oral intake; but he gained some weight back.  He should take nutritional supplements, we will monitor his weight.     Lab tests including serum LDH will be done along with a biopsy.  We will make further plans once we have a tissue diagnosis for the lymphadenopathy.  The results of his tests and plan of care were discussed with the patient and his family members, they were agreeable. Thank you for allowing me to participate in his care.          The time spent in this encounter was 60 minutes, more than half of which was spent in coordination of care and consultation.  This note was dictated using a voice recognition software.  Please excuse any typing errors not detected in proofreading and contact us if additional clarification is needed.      Chronic Problem List    Anorexia  Constipation  GERD (gastroesophageal reflux disease)  History of esophageal reflux  Nausea  Paronychia, finger  Rectal bleeding  SSBE (short-segment Barrett's esophagus)  Urinary hesitancy  Procedure/Surgical History  ?EGD - Esophagogastroduodenoscopy (05/20/2022) ?EGD - Esophagogastroduodenoscopy (05/15/2021) ?Left inguinal hernia repair (04/01/2021) ?Colonoscopy (01/24/2019) ?Colonoscopy (09/10/2008)   Surgical History Internal  05/20/2022    EGD Bx    MD  05/15/2021    EGD Bx    MD  04/01/2021    Hernia Repair Inguinal  (Left)    MD  01/24/2019    Colonscpy Diagnostic/Screen     MD  Medications  Home Medications (3) Active  multivitamin 1 Tablet, Orally, Daily  pantoprazole 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Married - One child - retired   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Alcohol abuse: Father.  Alzheimer's disease: Mother.                Signature Line Electronically Signed on 05/12/23 16:19 EDT ________________________________________________________ MD