CHIEF COMPLAINT: Metastatic esophageal carcinoma.
SUBJECTIVE: The patient is a (XX)-year-old male who presents today for followup of his metastatic esophageal carcinoma. The patient has completed two cycles of chemotherapy. The patient tolerated the chemotherapy well. He continues to do better. The patient has gained approximately 5 pounds. At the present time, the patient denies any headache, chills, sweating, fever, double vision, chest pain, nausea, vomiting, shortness of breath, abdominal pain, constipation, or diarrhea. The patient has normal urination. The patient is followed by the hematologist/oncologist on a regular basis. Next week, the patient is going to start the third cycle of chemotherapy. No radiation therapy at the present time.
For details of past medical history, past surgical history, medication, and allergies, refer to the chart.
REVIEW OF SYSTEMS: As per the history of present illness.
OBJECTIVE: Vital Signs: Blood pressure 110/78 mmHg, heart rate 98 beats per minute, and temperature 98.4 degrees. The patient is very thinly built, in no apparent distress. The patient is alert, awake, and oriented x3. Skin: No bruises and no rashes. He has erythematous rash under his palms and soles. Oropharynx is normal. Nose: Mucosa is red and moist, no ulceration. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Neck: Supple. No JVD or carotid bruits. He has anterior cervical lymphadenopathy, more on the left side, 0.5 in size, axillary lymphadenopathy 0.5 cm in size. Chest: Clear. Heart: Normal S1 and S2, regular rhythm. Abdomen: Soft. Not tender to palpation. Normoactive bowel sounds. No organomegaly. Extremities: No edema, cyanosis, or deformities.
ASSESSMENT AND PLAN: Esophageal carcinoma with metastasis: The patient is followed up by the hematologist/oncologist on a regular basis. The patient has completed two cycles of chemotherapy. The patient is going to start his third cycle of chemotherapy. The patient has had chronic pain. For the pain, we recommended Percocet 10/325 mg every 4 to 6 hours as needed. We recommend the patient continue present management. We will follow up the patient in one month.
SAMPLE #2
SUBJECTIVE: The patient reports she has had no fevers or chills. She has been on Neupogen for the past week due to neutropenia. Her Abraxane has been held the past week. She has received two doses of weekly Abraxane thus far and two doses of Avastin. She has had no fevers or chills. She has had some lower back discomfort from Neupogen.
OBJECTIVE: Blood pressure 134/82. Pulse 74. Weight 129 pounds. The patient is alert and oriented x3. Cognition is normal. The pharynx is clear without mucositis. The neck is supple without thyromegaly. There is no neck, axillary or inguinal adenopathy. The lungs are clear to percussion and auscultation. The cardiac exam is without rub or gallop. The abdomen shows no mass or organomegaly. The extremities are without edema. The neuropsychiatric exam is unremarkable. Breasts are without masses. There is a fullness in the right breast. It is indistinct.
LABORATORY DATA: WBC: 15,800. Hemoglobin: 13.8. Platelets: 118,000.
PLAN: The patient’s chemotherapy will be changed to Abraxane 260 mg/m2 q. 3 weeks, Avastin 10 mg/kg q. 3 weeks. She will receive Zometa today. She will receive the Avastin tomorrow. We will see her in followup in 3 weeks.
