DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Probable metastatic lung cancer.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gentleman who has a past history of prostate cancer. He was treated with both external beam treatment and seed implant. The patient tells me that a PSA was performed approximately one month ago and he had a PSA of 0.1; this is not confirmed on the chart. Nevertheless, over the past several months, he has presented with history of mid back pain. This has been associated with weight loss as well as fevers. He was found to have a white count as high as 50,000 and a CT scan of the thorax revealing a large mass involving the left hilum and left lower lobe and mediastinum, compatible with a neoplasm. Also, smaller nodules were seen on the right, which were indeterminate. He has gone on to have a bone scan performed showing multiple bony metastases, and he has also had an MRI of the spine, which shows extensive thoracic disease. There is paraspinal disease at T10 and some very early posterior extension at T11. He does not complain of weakness in his lower limbs, and he has not lost bowel or bladder control. This gentleman had a bronchoscopy this morning by Dr. Jane Doe, who called us today and indicated she saw an endobronchial lesion, which was biopsied. He has been referred for consideration of possible radiation treatment. It is important to note that this gentleman has also developed pathologic fracture of his right humerus, which has been recently pinned.
PAST MEDICAL HISTORY: Prostate cancer as noted above. History of hyperlipidemia and history of coronary artery disease with two previous stents placed. He has also had a balloon angioplasty.
MEDICATIONS: Altace, aspirin, atenolol, Plavix, Zocor, Centrum, Prilosec, and Naprosyn.
ALLERGIES: NKDA.
SOCIAL HISTORY: He is divorced. He quit smoking many years ago.
FAMILY HISTORY: There is no family history of malignancy.
REVIEW OF SYSTEMS: See the hospital chart for detailed system review. This gentleman’s main complaints are related to his pathologic fracture of his right humerus. He has also had mid thoracic pain, which has been radicular in nature. He has not noticed increased shortness of breath. He has had nonspecific weight loss, and he has had a history of fevers.
PHYSICAL EXAMINATION: On examination today, his vital signs, as documented in the hospital chart, are stable. He has just had a bronchoscopy and he is using oxygen by nasal prongs. There is no jaundice. His conjunctivae and eyelids were normal. He had full extraocular movements. His oral cavity and oropharynx were normal. There is no evidence of pathologic adenopathy in his head, neck or supraclavicular regions. Trachea is midline. Decreased air entry in the left lung base. His right lung fields are clear. He had a systolic ejection murmur of grade 2/6 to 3/6 over his precordium and his rate and rhythm were normal. There is no clubbing or axillary adenopathy. There are no abdominal masses. No tenderness. No hepatosplenomegaly. No inguinal adenopathy. There was no ankle edema. Power testing was grossly normal.
ASSESSMENT:
1. Previously treated prostate cancer. PSA is stable, appears to be controlled.
2. Evidence of bony metastatic disease with a pathologic fracture of his right humerus and a probable lung primary.
PLAN: Reviewed with this gentleman the findings. We have told him that we will need to await the biopsy result prior to initiating treatment. However, we believe palliative treatment would be indicated to the right humeral area. We believe the thoracic spine requires palliative treatment, particularly the T10-T11 region. As well, we may be able to encompass in the same radiation field, his lung lesion. Undoubtedly, he will also require systemic therapy. This gentleman is accepting of what was discussed. We will await the pathology report, and we will review him again in the middle of the week to ascertain and decide about initiating treatment.
Thank you for asking us to see this gentleman. We will follow the patient along with you.
