I am attaching here the medical report of my father in law for your inputs/recommendations. Diagnosis 1- Metastatic adenocarcinoma of unknown primary. 2- History of hemorrhagic stroke with left hemi paresis. 3- Sick sinus syndrome, status post pacemaker insertion. 4- Diabetes mellitus. 5- Essential hypertension. Of a 77 Y.O. male patient was admitted to hospital on January 10th, 2010 with higher upper quadrant pain associated with fever of 39.5 degrees C. he reported no respiratory symptoms. He had no hematemesis of Melina. The patient reported that he had been feeling week for several months and lost about 09 KGS. From 80 Kg A year ago to 71Kg. He reported extreme weakness from being fully ambulatory till several weeks before presentation to being bed bound and poorly responsive now. The patient did not have any new reparatory symptoms. He is an ex smoker. He quit almost 50 years ago. Since admission, the patient has had a workup that showed multiple liver masses with multiple abdominal lymphadenopathy mostly in the porta hapatis and gastro esophageal junction area. Examination revealed an elderly male who looked very week. He had no cervical, axillary or inguinal lymphadenopathy. His chest showed good air entry interiorly. His abdomen was soft with mid right upper quadrant tenderness. the liver was palpable, mostly in the epigastria region, about 5 cm. Genitalia showed no masses. Significant Investigation; Hemoglobin was 11g/dt. LDH 725 and alkaline phosphates 139. ALT and AST were normal. CEA was increased to 9.6 and CA19-9 was 70. Alpha-fetoprotein and PSA were normal. CT of the chest showed a small right pleural effusion. There was severe bilateral central labural emphysema. There was basilar sub-segmental atelectasis. CT of the abdomen showed multiple enhancing liver lesions, The largest two involved the anterior segment of the right liver lobe and the medial segment of the left liver lobe, and measured 8.7 x 6.7 cm and 7.7 X 7.2cm respectively. The interior vena cave was severely compressed by the right anterior liver lobe segment lesion, however it resumes it s normal caliber in the suprahepatic inferior vena cave level. There were multible sub-centemeter lymph nodes just below the level of the gastro esophageal junction with an average size of 1.2 x 0.8cm. However, there are larger lymph nodes measuring 1.2cm in the shortest axis, mainly in the peri-celiac an porta hepatis region where multiple enlarged lymph nodes are also present. There were also multiple sub-centimeter peri-aortic lymph nodes. The prostate was significantly enlarged and heterogeneous, likely due to heterogeneous enhancement. The maximum obtained diameters are 6.5 x 8 x 8.7cm in the AP. transverse and sagittal diameters respectively. A CT-guided liver biopsy showed a poorly differentiated adenocarcinoma. Recommendation Palliative care was recommended. Please revert back with your best possible recommendation to treat my father in-law. Best regards,