4th Qtr 2016 Medicare Nursing Case Study #2
71yof-CT Chest, Abdomen and Pelvis w (71260), (74177)
AETNA MEDICARE SPECIAL (NC)
To MD Review: Per: Faxed Notes.
LOV: 9/12/16.
Reason: Surveillance & follow up lung nodule.
ONC member hx Updated X Verified ___ Reviewed ___
Prior Imaging: 6/7/16 PET: Faint activity in L apical pulmonary nodule unchanged since 2/16/16.
2/16/16 CT C/A/P w: Slight interval enlargement of LUL nodule (this has slowly increased in size since 6/7/14), now 9 x 6mm. Tiny R pulmonary nodules are stable. Stable infiltration of omental fat, probably metastatic.
PE: No abnormal findings.
Sx: Persistent issues with fecal urgency, fatigue and maintaining appetite/gaining wt.
Labs: 6/2016 Chromogranin A 47. 2/2016 Chromogranin A: 41.
Nurse Comment: ONC-15.5, CH-16.1: Prior abdominal/pelvic imaging may suffice. CT Chest w may be appropriate for lung nodule
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