Question

Progress Notes

This 50-year-old patient has had a progressively worsening headache for 6 months, and episodic weakness of his R leg for the past several months. These episodes last 5 to 10 minutes and are described as “numbness” or clumsiness of gait, with inability to walk or lift the leg. Has noted a dark mole that progressively enlarged on the upper tip of the R earlobe over the past 3 yr. Suspected a melanoma but did not consult a physician.

FH/SH: denies sun exposure. No fam. hx of cancer. Works as a clerk. No children. Unmarried.

ROS: Smoker (30 pack yr) but not known to have COPD. Heart—no known disease. Had total colectomy for ulcerative colitis at age 12. No Sx since. Has lost about 10 pounds in past few months. CT and MRI demonstrate R and L cerebral lesions.

Chest: multiple 1 cm nodules. PE: Pale, asthenic, bearded man in NAD (no apparent distress). Conversation appropriate. Large, 1cm long bluish mole on R earlobe. No other susp. Lesions. No nodes. Clear to A&P

Abd: no hepatomegaly or splenomegaly

Extr: no edema, tenderness

Neurol: Oriented and knows president and candidates No apparent motor defect. Touch intact

Reflexes good in knees and ankles

Impression:

1. Likely melanoma met. to brain and lung. Bx results pending.

2. COPD

Suggest

1. RT for brain lesions (no role for surgery)

2. Consult melanoma service

3. Social service evaluation

4. ?HIV status

Answer the following: (abbreviations must be spelled out)

1. Patient’s history indicates two abdominal surgeries, name and describe them. _________________________________________ and _________________________________

2. Examination of the abdomen indicates ______________________of two organs. Name the organs ____________________________ and __________________________________

3. Name the respiratory condition the physician suspects _________________________ _________________________________.
4. Name the two diagnostic procedures that confirmed brain lesions: _____________________________________ and _____________________________________
5. The brain lesions are the result of: (provide the medical term) __________________________________.

Answer 1

Patient’s history indicates two abdominal surgeries, name and describe them. *Pancolectomy i.e. Removal of full length colon due to continuous involvement in Ulcerative colitis* and *illeoanal pouch formation for maintaining normal defaecation*

Examination of the abdomen indicates *palpation* of two organs. Name the organs *Liver* and *Spleen*

Name the respiratory condition the physician suspects *Chronic obstructive pulmonary disease*

Name the two diagnostic procedures that confirmed brain lesions: *Computed Tomography* and *Magnetic Resonance Imaging*

The brain lesions are the result of: (provide the medical term) *Metastasis of Malignant Melanoma*.