DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with a history of Lynch syndrome. He has a stage IV colon cancer with metastases to liver and lungs. Recently, he has progressed on FOLFIRI and Avastin. He has recently been evaluated and recommended treatment with HAI. He will proceed with this after the holidays. Today, he has a few complaints. He does note that he has moderate pain in the right side, both right upper and lower quadrants. He currently takes Vicodin 10/325 q. 4 hours for this.
Since he has been taking his pain medicine, he has had some problems urinating. He is no longer able to urinate from a standing position and has to urinate while seated due to inability to initiate the urine stream.
Past medical history, past surgical history, family history, and social history are unchanged from previous dictations.
ALLERGIES AND MEDICATIONS: Reviewed and updated.
REVIEW OF SYSTEMS: A comprehensive 12-point review of systems is otherwise within normal limits.
PHYSICAL EXAMINATION:
VITAL SIGNS: Reveal a heart rate of 144, respiratory rate of 16, and blood pressure is within normal limits.
GENERAL: Alert and oriented x4, in no apparent distress.
HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear. There is no cervical lymphadenopathy.
HEART: There is a noted tachycardia. No murmurs, rubs or gallops appreciated.
LUNGS: Clear to auscultation bilaterally. No wheezing.
ABDOMEN: Slightly tender with no rebound or guarding on the right side of the abdomen.
EXTREMITIES: No edema, no erythema.
SKIN: No rash or lesions.
NEUROLOGIC: Cranial nerves grossly intact.
PSYCHIATRIC: Normal affect and mood.
LABORATORY DATA: No new labs at this time.
IMAGING DATA: No new imaging at this time.
IMPRESSION AND PLAN: The patient is a (XX)-year-old male with history of colorectal cancer and Lynch syndrome as described above. He has recently progressed on FOLFIRI, Avastin and is due to begin therapy with hepatic arterial infusion. We are concerned for his heart rate. He is asymptomatic, and upon further questioning, he also notes some darkening of his urine despite drinking 3 liters of water each day.
We will order a stat. EKG to be performed here in the clinic as well as labs, including CBC, electrolytes, kidney function, and liver function tests and urinalysis with urine and blood cultures as well. We told him that the etiology of his tachycardia could be due to the concomitant infection and have asked that he return to clinic or the emergency room immediately if he feels febrile or has any malaise or other symptoms. This could also be due to pain, which he continues to have despite Vicodin, and we have added a long-acting MS Contin to his regimen 15 mg p.o. q. 12 hours but instructed him that he may take it q. 8 hours if q. 12 hour dosing does not significantly relieve his pain and allow him to take much less Vicodin.
Otherwise, we will have him follow up as scheduled and have him return here in two months for followup. He agrees with this plan. All his questions have been answered to his satisfaction. We will follow up on his EKG and laboratory evaluations.
