C.G.
The history of C.G. is that he is a former smoker, 69-year-old male with cancer in the head and neck (a radical neck dissection was performed in 2012), which has recently metastasized in the liver and lungs, as indicated by PET scan which shows metabolic activity. The patient suffers from moderately-severe depression with a PHQ-9 score of 15 (Kroenke, Spitzer, Williams, 2001) and refuses anymore chemotherapy. He is at a point now where he wants to know his options for what remains of the rest of his life, indicating that he is not willing to undergo any further treatment for the his cancer or its spread.
The results of the physical show that C.G. suffers from hypertension, hyperlipidemia, stomatitis, anemia, and neutropenia. He is currently receiving 12.5 mg of Carvedilol daily plus 40 mg of Furosemide daily. His BP indicates that he has "isolated systolic hypertension" and it is likely that the treatment for and failure to stop the spread of his cancer has contributed to the stress that his body his under, which is registered in his mental and emotional fatigue and desire to cease all treatment for the cancer. The rest of the physical has not revealed any serious problems or defects other than the expected limited range of motion in the head/neck and Ronchi detected in the lungs.
The differential diagnosis suggests liver cancer, adjustment disorder, and chemotherapy side effects, but the primary diagnosis is metastatic cancer. The rationale for the primary diagnosis is the evidence of metabolic activity in the liver and lungs as well as in the neck, indicating that the cancer has indeed spread throughout the body (Berman, 2004). The rationale for the differential dx -- liver cancer -- is based on the same indications but ignores the possibility of the spread of the cancer from the neck (Berman, 2004)....
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