DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Abnormal CT of the chest.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old gentleman who is followed for atrial fibrillation. He apparently failed treatment with amiodarone, and because of recurrent problems with the atrial fibrillation, he is being considered for ablation. Part of his evaluation included an MRI, which showed some adenopathy. Subsequently, a CT of the chest was done, which confirmed the presence of hilar mediastinal adenopathy. We were asked to see the patient. The patient was admitted for an ablation. He is awake and responsive, in no acute distress on room air. He denies any chest pain, cough, or wheezing. He does have some skin problems.
PAST MEDICAL HISTORY: Atrial fibrillation, non-insulin-dependent diabetes mellitus, obesity, some thyroid problems due to amiodarone, hypertension, hyperlipidemia, and depression.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: He does not smoke or drink. He is married.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fevers, night sweats, or weight loss.
NEUROLOGIC: He denies any history of seizure, stroke, migraine headache.
CARDIAC: No history of MI, palpitations, or CHF.
PULMONARY: Never had asthma or emphysema.
GASTROINTESTINAL: No ulcer, colitis, or hepatitis.
GENITOURINARY: No kidney or bladder problem.
MUSCULOSKELETAL: No history of gout or rheumatoid arthritis.
All other systems are negative.
PHYSICAL EXAMINATION:
GENERAL: He is awake, responsive, in no acute distress.
VITAL SIGNS: Blood pressure 168/90, pulse 62, temperature 98.4.
HEENT: Pupils round and reactive. Sclerae anicteric.
NECK: Supple without JVD, goiter, or carotid artery bruit.
HEART: S1, S2. No murmurs or gallop. PMI is in normal position.
LUNGS: Clear to auscultation without rales, rhonchi, or wheezes. Tactile fremitus is diminished.
ABDOMEN: Obese, soft, and nontender. Could not appreciate any organomegaly.
EXTREMITIES: No edema or clubbing.
SKIN: Warm, no rashes. He has got a lot of acne on his back. No lymphadenopathy in the neck, supraclavicular, or axillary area.
NEUROLOGIC: Nonfocal. Cranial nerves are intact.
DIAGNOSTIC DATA: CT of the chest was reviewed and indeed it does show bilateral hilar mediastinal adenopathy ranging in the range of 2.0, 2.5 being the largest and the smallest was 1.3 x 2.0. No parenchymal nodules, infiltrate, or effusions are seen.
LABORATORY DATA: Sodium 136, potassium 3.7, chloride 102, bicarbonate 24, BUN 14, creatinine 0.8. Liver enzymes are normal. CBC is pending.
IMPRESSION: The patient is a very pleasant (XX)-year-old gentleman with history of bilateral hilar and mediastinal adenopathy, the cause of which is unclear. The adenopathy is in the upper limits of normal to slightly pathological, as some of them are greater than 2 cm. We favor, from the general appearance of the CAT scan, a more benign disease such as inflammatory process, or sarcoidosis could be causing this presentation. We doubt lymphoma or malignancy.
RECOMMENDATIONS: At this point in time, we have two options. One is a conservative followup and the other one is a transbronchial biopsy. We will discuss this with the patient.
Thank you for consulting us. We will follow the patient with you.
