DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: New diagnosis of grade 2 follicular non-Hodgkin lymphoma.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old, otherwise quite healthy female who initially presented to the emergency room with abdominal pain. At the time of her admission, she was found to have significant lower extremity swelling as well as elevated liver function enzymes, creatinine of 1.6, and bilirubin of 2.6. CT scan of the abdomen obtained at the time of admission showed evidence of retroperitoneal adenopathy with associated bilateral hydronephrosis and possible distal common bile duct blockade. Subsequent MRI of the abdomen and pelvis was obtained showing findings concerning for mass at the ampulla with obstruction of the distal common bile duct and pancreatic duct with again noted bilateral hydronephrosis, bladder diverticula, and retroperitoneal adenopathy.
Gastrointestinal consultation was obtained, and although cannulation of the bile duct was attempted, this was not able to be performed. Subsequently, however, she has had improvement in her liver enzyme abnormalities with supportive care. She underwent CT-guided lymph node biopsy. This reveals evidence of a follicular grade 2 non-Hodgkin lymphoma, Ki67 50%, and CD20 positive.
PAST MEDICAL HISTORY: Significant only for previous abdominal surgery, including ventral hernia repair, total abdominal hysterectomy with right-sided oophorectomy and previous appendectomy.
MEDICATIONS: She is on no regular medications.
ALLERGIES: She has no medication allergies.
MEDICATIONS: In the hospital include hydrocodone as needed, amlodipine, Ancef, allopurinol 200 mg daily, Zosyn as needed, and ondansetron.
REVIEW OF SYSTEMS: Negative for fevers, chills, night sweats, nausea, vomiting but positive for poor appetite, positive for abdominal pain, which has improved, positive for lower extremity edema. Negative for skin rash, negative for dysuria, negative for focal neurologic problems.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 166/76, temperature 36.6, heart rate 82, respiratory rate 20, and O2 sat 95% on room air.
GENERAL: This is a pleasant, alert, oriented, elderly female in her hospital bed, in no acute distress.
HEENT: Normocephalic and atraumatic. She has no oropharyngeal lesions or thrush.
LUNGS: Clear.
HEART: Regular rate and rhythm without murmurs, clicks or rubs.
ABDOMEN: Soft and nontender and no masses are palpated.
EXTREMITIES: She has 2+ pitting edema to the knee bilaterally.
LABORATORY AND DIAGNOSTIC DATA: Recent laboratory studies show white count 6.6, hemoglobin 11.8, hematocrit 36.4, and platelet count 284, creatinine 0.9, BUN 24, electrolytes normal, alk phos 190, which is improved, ALT 120, which is improved, AST 88, which is improved. Total bili 3.5, albumin 3.2, LDH elevated at 602, uric acid elevated at 8.8. Radiology results and pathology as above.
IMPRESSION:
1. Follicular grade 2 non-Hodgkin lymphoma with bulky retroperitoneal and abdominal adenopathy.
2. Likely incomplete obstruction of common bile duct from underlying lymphoma and adenopathy.
3. Hydronephrosis, likely secondary to follicular grade 2 non-Hodgkin lymphoma with bulky retroperitoneal and abdominal adenopathy.
4. Bilateral leg swelling, slightly improved, likely from lymphomatous blockade of venous return.
5. Elevated uric acid.
6. Mild normocytic anemia.
PLAN: We have reviewed her diagnosis, treatment options, prognosis, and goals of care of her grade 2 follicular non-Hodgkin lymphoma. Her age, frailty, and risk of tumor lysis syndrome are substantial. However, her treatment options are generally effective at inducing a response and long-term remission is possible with appropriate therapy. The patient is otherwise healthy, despite her advanced age. We recommended initiation of daily prednisone at 40 mg per day, and we have discussed the initiation of single agent rituximab as a way to induce a treatment response at low risk of tumor lysis syndrome. This may enable a period of improvement that will allow for strengthening and discharge home and may open up additional chemotherapeutic options, which may be more aggressive but result in more prolonged remission, like combination rituximab with bendamustine.
