DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Progressive non-small cell lung cancer.
HISTORY OF PRESENT ILLNESS: The patient is an unfortunate (XX)-year-old Hispanic male originally seen last month for further evaluation of a locally-advanced adenocarcinoma involving the left lung. The patient had originally presented with progressive decline in health for six to eight weeks prior to hospitalization. He had a substantial reduction in his oral intake with a reported 40-pound weight loss over the past six months.
He complained of left-sided anterior pleuritic chest pain of six weeks’ duration. Subsequent evaluation included a CAT scan demonstrating bilateral interstitial lung disease with associated bronchiectasis and pleuroparenchymal scarring with moderate mediastinal lymphadenopathy. CT of the abdomen revealed focal infiltrate involving the left lung base with minimal infrarenal abdominal aortic aneurysm.
A subsequent bronchoscopy identified extensive cobblestoning with erythema and friability involving the left upper lobe lingular segments, as well as the left lower lobe bronchi. Biopsies confirmed non-small cell malignancy favoring adenocarcinoma. The patient gives remote history of a squamous cell carcinoma involving the sinuses, undergoing full definitive radiation therapy. He has a long-standing history of tobacco use in the past.
The case was discussed with his caregivers at the nursing home, and the patient was originally admitted last month, subsequently discharged to nursing home. Since the discharge to nursing home, he has required total care including assistance with bathing, feeding, and eating.
He now presents with marked hypoxia requiring Venti-mask, continuing to require total care, unable to feed or bathe himself. His appetite remains quite poor. He continues to complain of mild central chest pain. He has noted a moderate cough, but he is unable to clear his secretions. Chest x-ray demonstrates complete white-out involving the left lung.
PAST MEDICAL HISTORY: Includes advanced chronic obstructive pulmonary disease, previous squamous cell carcinoma of the sinus, status post definitive radiation therapy, low back injury with resulting disability, recurrent bronchitis, iron deficiency, interstitial lung disease, and bronchiectasis.
MEDICATIONS: Include Xanax 0.25 mg daily, Fortaz 1 g IV q. 8 h., Decadron 4 mg intravenous q. 6 h., Cardizem drip presently 30 mg daily, Levaquin 500 mg daily. Medications at nursing home included Spiriva inhaler daily, Mucomyst nebulizer t.i.d. x10 days, Xanax 0.25 q. 12 h., Ceftin 500 mg twice daily, recently discontinued, Combivent inhaler 2 puffs q.i.d., Prevacid 30 mg daily, ferrous sulfate 325 mg b.i.d., Megace as mentioned 800 mg daily, and oxygen 3 liters titrated.
SOCIAL HISTORY: The patient was previously living at home by himself. The patient admits to smoking one pack of cigarettes daily for over 40 years. The patient admits to consuming six packs of beer on a daily basis. He indicates that he had quit tobacco use in June. He had quit alcohol use over two years ago.
FAMILY HISTORY: Noncontributory.
VITAL SIGNS: Include a blood pressure 112/88, respirations 22, pulse 110, and T-max 98.4.
SKIN: Skin evaluation reveals extreme generalized pallor with areas of subcutaneous ecchymosis in the previous venipuncture site. There is marked bitemporal wasting and substantial generalized muscle wasting.
HEENT: The oropharynx is dry without mucosal lesion.
NECK: No palpable cervical or supraclavicular lymph nodes are present.
LUNGS: There are diffuse bilateral scattered expiratory wheezes with markedly diminished breath sounds throughout the left lung field with bronchial breath sounds present.
HEART: Increased rate. Frequent ectopy. No S3.
ABDOMEN: Soft and scaphoid.
EXTREMITIES: Without erythema or edema.
NEUROLOGICAL: He is mildly anxious with no apparent cranial nerve deficits. No apparent focal, motor or sensory deficits noted.
LABORATORY DATA: CBC: White count 15.3, hemoglobin 10.6, and platelet count 564, 000. Basic metabolic profile reveals grossly normal parameters. CPK normal at 33. Radiographic studies as indicated.
1. Progressive adenocarcinoma involving the left upper and lower endobronchial segments, now with complete opacification suggesting obstruction.
2. Continued profound decline in performance status, currently requiring total care. The patient has required significant assistance now since his hospitalization.
3. Mild cancer-related pain.
4. Anorexia, cachexia, and malnutrition.
5. Advanced chronic obstructive pulmonary disease.
RECOMMENDATIONS: The patient’s performance status is exceedingly poor. He is clearly not a candidate for any type of systemic chemotherapy for his cancer, and we believe that radiation would provide very marginal benefit. One could consider the possibility of ultrasound and potentially remove any fluid. Unfortunately, this will be a transient improvement.
In our opinion, the patient is not a candidate for any type of aggressive systemic treatment for his cancer and would benefit from palliative supportive care with hospice intervention. We will discuss the above findings with the doctors involved in the case as well as his family.