Identification Number
9522012113
Telephone Number
079971938
Record Created
2026-07-27 08:30
Last Updated
2026-07-27 08:51
History of Present Illness (HPI)
74Y FEMALE
HTN, PRE-DIABETIC
C/O Epigastric pain, Abdominal distention
No weight loss, no bleeding per rectum.
Medical Conditions
2 record(s)
| Condition |
Type |
Diagnosis Date |
ICD-10 |
Severity |
Status |
Notes |
| Dm |
Chronic |
- |
- |
- |
Active |
- |
| Hypertension |
Chronic |
- |
- |
- |
Active |
- |
Family Medical History
0 record(s)
No family medical history was recorded.
Social History
No social history was recorded.
Surgeries
0 record(s)
No surgery records were recorded.
Chemotherapy
1 record(s)
Treatment Plan
4 cycles of FOLFOX GIVEN
C1 23/4/2026
C2 11/5/2026
C3 4/6/2026
LAST DOSE - 18/6/2026
Radiology Records
3 record(s)
Impression
Large ugly looking lesion in incisura, multiple Bx taken.
Impression
Previously noted circumferential wall thickening in the distal descending colon is significantly improved.
Oedematous circumferential wall thickening is noted in the stomach with no significant changes regarding the previously noted lymph nodes.
Findings
The scope was entered up to 50cm from AV, there is ugly looking circumferential wall thickening causing narrowing of the lumen, the scope could not be bypassed.
Biopsies not taken because the pt already have the biopsies showing - invasive moderately differentiated colonic adenocarcinoma
Specialist Opinions
1 record(s)
Opinion Note
Lt hemicolectomy and total/subtotal gastrectomy
Laboratory Tests
4 record(s)
| Date |
Test |
Category |
Result |
Reference Range |
Status |
Notes |
| 2026-04-12 |
Hepatitis Profile |
Other |
Negative
|
- |
Normal |
- |
| 2026-03-16 |
CA19-9 |
Tumor Markers |
3.79
U/ml
|
0-39 |
Normal |
- |
| 2026-03-16 |
CA125 |
Tumor Markers |
7.59
U/ml
|
0-35 |
Normal |
- |
| 2026-03-16 |
CEA |
Tumor Markers |
9.28
Ng/ml
|
Up to 3 (non smoker), up to 5 (smoker) |
High |
- |