4th Qtr 2016 Onc Nursing Case Study #3
57yof-MRI brain wo/w contrast (70553)
CIGNA SAR SI-OAP/PPO
Source of Information or Caller Name and Location: fax
Check member history (select one)
( _ ) Not present; ( x ) Applicable history is not present; ( _ ) Applicable history present: _______
Additional Information provided:
LOV: 11/7/16
Reason: follow up - L breast IDC and poorly diff adeno DOD 4/8/13
ONC Member Hx: verified
Prior Imaging: No relevant imaging provided.
PE ECOG PS 0, dentition abnormal, teeth missing, Left supraclavicular lymph nodes +, Palpable lymph nodes in the left axilla, tenderness to palpation in the left upper anterior chest wall with soft tissue thickening, The liver margin is just palpable at the right lateral costal margin.
Sx: left upper extremity swelling and left upper chest wall and left breast swelling and heaviness and pain., malaise, muscle aches, muscle cramps, breast tenderness
Labs: LFTs and tumor markers not provided
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