DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Double-lumen Groshong catheter.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old Hispanic male with newly diagnosed T-cell lymphoblastic lymphoma and is in need of double-lumen Groshong for chemotherapy. He is also awaiting a bone marrow biopsy for final staging. The patient was transferred over here from an outside facility. The plan is to hopefully start chemotherapy on Wednesday and transfer him to the bone marrow unit. Later today, a consult will also be out for Pediatric Hematology, possibly to assume the patient’s care. The patient will be starting tumor lysis syndrome prophylaxis as well.
PAST MEDICAL HISTORY: Essentially negative, except for the newly diagnosed T-cell lymphoblastic lymphoma.
PAST SURGICAL HISTORY: Status post biopsy of lymph node in the right neck.
ALLERGIES: No known allergies.
FAMILY HISTORY: Essentially negative, except for grandfather who had tuberculosis.
SOCIAL HISTORY: Negative tobacco. Negative ETOH use.
REVIEW OF SYSTEMS: Sore throat just for about three to four weeks. No significant weight loss. Just had some vomiting today after breakfast, however this is new. Denies any actual high fevers, although he states he has had some low-grade temperatures and chills. He developed some neck swelling and some swelling of his tonsils and also he was felt to have some tonsillitis. Otherwise, he has been healthy and no other symptoms.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 134/70, pulse 62, respirations 18, temperature 98.2 degrees.
GENERAL: The patient is a thin Hispanic male who appears actually older than his stated age.
HEENT: Normocephalic and atraumatic. There is no scleral icterus.
NECK: There was extensive bilateral cervical adenopathy. The right neck biopsy site incision is clean, dry, and intact.
HEART: Regular rate and rhythm. Normal S1, S2. No obvious, murmur, rub or gallop heard.
LUNGS: Clear bilaterally to auscultation with symmetrical chest excursion. There is axillary adenopathy as well, left greater than right.
ABDOMEN: Soft and nontender. No peritoneal signs elicited.
EXTREMITIES: Warm without any cyanosis or clubbing. No peripheral edema noted.
LABORATORY DATA: WBC is 75.4, platelets 142, hemoglobin 16.8, hematocrit 48.9, neutrophils 10.2%, bands 12.2%, and lymphocytes 65%. Electrolytes are within normal limits, except creatinine of 1.23. LFTs within normal limit. LD is elevated at 300. Uric acid is 6.2, magnesium 1.9. HIV is pending.
DIAGNOSTIC DATA: CT scan of the neck shows extensive bilateral submandibular and supraclavicular adenopathy. There is a large soft tissue mass in the anterior-superior mediastinum, enlarged adenoids and tonsils as well. CT of the abdomen shows no acute abdominal abnormalities. No abdominal mass or adenopathy. CT of the pelvis shows ST nonspecific with nonenlarged inguinal lymph nodes seen bilaterally. There are no pathologically enlarged lymph nodes. CT of the chest shows an anterior mediastinal mass. There is no associated middle or posterior mediastinal lymphadenopathy or hilar lymphadenopathy or lung densities.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old male with newly diagnosed T-cell lymphoblastic lymphoma needing a Groshong catheter for chemotherapy. We will review history and examination findings. Surgical plans will be forthcoming.
