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.

ALLERGIES: None.

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.

PHYSICAL EXAMINATION:
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.

IMPRESSION:
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.

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REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Deep venous thrombosis/pulmonary embolism.

HISTORY OF PRESENTING ILLNESS:  The patient is a (XX)-year-old female with past medical history significant for Crohn disease. The patient has a remote history of superficial phlebitis. The patient was not put on any anticoagulation at that time, and her symptoms resolved after a few days. The patient was admitted through the emergency room since she developed pain and swelling involving the left lower extremity. The patient said that she apparently had pain in her left mid thigh region, and there was apparently some swelling in the left groin region.

At presentation, she underwent Doppler studies of the left lower extremity and a clot was identified in the proximal greater saphenous vein extending into the knee area of the greater saphenous vein. The patient also underwent a CT scan of the chest and pulmonary embolus was identified and as such hematology consultation was requested. The patient gives a history of being on birth control related contraception in the recent past. The patient denies having any family history of any bleeding or clotting problems. Family history is significant for varicose veins.

PAST MEDICAL HISTORY:  As above and significant for Crohn disease.

PHYSICAL EXAMINATION:  The patient is lying in bed and appears to be in no acute distress. Vital signs are stable, afebrile. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reacting to light. Neck: Supple. No JVD. Chest: Clear to auscultation. Heart: S1, S2. Abdomen: Soft and nontender. Neurologic: No gross neurologic deficits. Extremities: The patient has some varicose veins involving the left lower extremity. The patient has an area of erythema and ecchymosis involving the left knee region. No obvious discernible swelling identified in the left groin.

LABORATORY DATA:  Lab investigations show WBC count of 6.8, hemoglobin of 13.2, hematocrit of 39.4, and platelet count of 236,000. PTT 28, INR 1.04. Sodium 136, potassium 3.3, chloride 106, carbon dioxide 28, glucose 92, BUN 15, and creatinine 0.9. Normal liver function tests.

IMPRESSION:  Deep venous thrombosis/pulmonary embolism. The patient is hypercoagulable.

PLAN:  Plan would be to initiate hypercoagulable testing consisting of prothrombin gene mutation 20210A, factor V Leiden, anticardiolipin antibody IgG and IgM. Would also obtain homocysteine levels. Would do Coumadin teaching through pharmacy. The patient can follow up at the Coumadin Clinic for her anticoagulation. Anticoagulation would be recommended for a six-month duration at this point in time unless the patient has any positive hypercoagulable tendencies. The case was discussed at length with the patient, and she was made aware of these recommendations.

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REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Neutropenia and anemia.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with past medical history significant for systemic lupus erythematosus diagnosed about two years ago. The patient was on prednisone 10 mg a day, which was recently stopped prior to the patient getting admitted to the hospital. The patient was admitted with complaints of abdominal pain, which apparently started about three months ago. The patient has had multiple evaluations in the past, but no apparent etiology for abdominal pain has been established at this point in time. Upon admission, the patient was found to have elevated liver function tests. The patient was also found to have fevers over the last three to four weeks. After admission, the patient was found to be anemic and neutropenic and as such hematology consultation was requested. The patient has been aware of anemia but denies any awareness of neutropenia. The patient has been menstruating but her menstruation has not been heavy in the past. She does complain of nausea but denies having any vomiting or diarrhea. Pain in the abdomen is in the left upper quadrant. The patient’s white blood cell count on admission was 3100 with 66% neutrophils, hemoglobin was 10.4, and platelet count was 192,000.

PAST MEDICAL HISTORY:  As above.

PAST SURGICAL HISTORY:  As above.

ALLERGIES:  No known allergies.

PHYSICAL EXAMINATION:  The patient appears to be in no acute distress. Vital signs are stable. T-max is 101.2 degrees. HEENT: The patient has facial rash. Neck: Supple. No JVD. Chest: Clear to auscultation. Heart: S1, S2. Abdomen: Soft. Mild tenderness in the left upper quadrant. Bowel sounds are present. Neurologic: No gross neurologic deficits.

LABORATORY DATA:  WBC count 3.1, hemoglobin 9.2, hematocrit 27.4, MCV 84, platelet count 162,000. PTT 33, INR 1.04. Sodium 133, potassium 3.9, chloride 106, carbon dioxide 24, glucose 96, BUN 9, creatinine 0.9, calcium 7.6, albumin 2.4, total protein 6.9, globulin 4.4, total bilirubin 0.6, alkaline phosphatase 238, ALT 138, AST 378, amylase 68, lipase 278.

IMPRESSION:
1.  Neutropenia, likely due to autoimmunity secondary to systemic lupus erythematosus.
2.  Normocytic-normochromic anemia, likely as a consequence of anemia of chronic disease from systemic lupus erythematosus as well, but other possible etiologies have to be ruled out.

RECOMMENDATIONS:  Would obtain serum immunofixation, LDH, vitamin B12 and folate levels. An iron panel would be done as well. Coombs test, both direct and indirect, would be done as well along with the reticulocyte count. The patient would need to be evaluated for systemic lupus erythematosus. Should the patient’s hematocrit drop below 25, then we can consider transfusing packed RBCs. The patient’s white blood cell count is adequate at the present time, and there is no need for any cytokine support. We would continue to follow this patient with you.

Thank you, Dr. John Doe, for involving us in the care of this patient.

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