Consult - History and Phy.
Sample Name: Gen Med Consult - 26
Description: Patient presents complaining of abdominal pain and discomfort for 3 weeks.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Abdominal pain and discomfort for 3 weeks.
HISTORY OF PRESENT ILLNESS: The patient is a 38 year old white female with no known medical problems who presents complaining of abdominal pain and discomfort for 3 weeks. She had been in her normal state of health when she started having this diffuse abdominal pain and discomfort which is mostly located in the epigastrium and right upper quadrant. She also complains of indigestion and right scapular pain during this same period. None of these complaints are alleviated or aggravated by food. She denies any NSAIDs use. The patient went to an outside hospital where a right upper quadrant ultrasound showed no gallbladder disease, but was suspicious for a liver mass. A CT and MRI of the abdomen and pelvis showed a 12.5 X 10.9 X 11.1 cm right suprarenal mass and a 7.1 X 5.4 X 6.5 cm intrahepatic mass in the region of the dome of the liver. CT of the chest revealed multiple small (<5 mm) bilateral lung nodules. Total body bone scan had no abnormal uptake. She was transferred to Methodist for further care.
The patient reports having a good appetite and denies any weight loss. She denies having any fever or chills. She has noticed increasing dyspnea with moderate exercise, but not at rest. She denies having palpitations. She occasionally has nausea, but no vomiting, constipation, or diarrhea. Over the last 2 months, she has noticed increasing facial hair and a mustache.
There is an extensive family history of colon and other cancers in her family. She was told there is a genetic defect in her family but cannot recall the name of the syndrome. She had a colonoscopy and a polyp removed at the age of 14 years old. Her last colonoscopy was 2 months ago and was unremarkable.
PAST MEDICAL HISTORY : None. No history of hypertension, diabetes, heart disease, liver disease or cancer.
GYN HISTORY: Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal.
FAMILY HISTORY: Mother is 61 years old and brother is 39 years old, both alive and well. Father died at 48 of colon cancer and questionable pancreatic cancer. One paternal uncle died at 32 of colon cancer and bile duct cancer. One paternal uncle had colon cancer in his 40s. Thirty cancers are noted on the father’s side of the family, many are colon; two women had breast cancer. The family was told that there is a genetic syndrome in the family, but no one remembers the name of the syndrome.
SOCIAL HISTORY: No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children.
VS: T 97.6 BP 121/85 P 84 R 18 O2 Sat 100% on room air
GEN: Pleasant, thin woman in mild distress secondary to abdominal pain and discomfort.
HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Sclerae clear. Pink conjunctiva. Moist mucous membranes. No oropharyngeal lesions.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, gallops, rubs.
BREASTS: Symmetric, no skin changes, no discharge, no masses
ABDOMEN: Soft with active bowel sounds. There is minimal diffuse tenderness on examination. No masses palpated. There is fullness in the right upper quadrant with negative Murphy’s sign. No rebound or guarding. The liver span is 12 cm by percussion, but not palpable below the costal margin. No splenomegaly.
PELVIC: not done
EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.
NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.
LYMPH: No cervical, axillary, or inguinal lymph nodes palpated
SKIN: warm, no rashes, no lesions; no tattoos
CT Chest: Multiple bilateral small (<5 mm) pulmonary nodules, no mediastinal mass or hilar adenopathy.
MRI Abdomen: 12.5 x 10.9 x 11.1 cm suprarenal mass, 7.1 x 5.4 x 6.5 cm intrahepatic lesion in the region of the dome of the liver, abnormal signal intensity within the inferior vena cava at the level of porta hepatic worrisome for thrombus.
Total Body Bone Scan: No abnormal uptake.
HOSPITAL COURSE: The patient was transferred from an outside hospital for further workup and management. She was taken to the Operating Room for abdominal exploration. A liver biopsy was done.
Keywords: consult - history and phy., abdominal pain, suprarenal mass, colon cancer, colonoscopy, abdominal, cancers,