Upper Lung Mass Consult Sample Report
DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Left upper lung mass.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with past medical history significant for anxiety, depression, and hepatitic C. The patient does have history of tobacco use. The patient presented with a complaint of left shoulder pain. The patient stated that the pain is achy in nature, comes and goes over the past 24 hours. The pain had been worsening to the point of left-sided chest pain, worsening, and radiated down to the left upper extremity with increased shortness of breath, especially during these episodes.
The patient stated that she was seen in the emergency department yesterday for back pain and was sent home. However, the pain continued to persist. The patient complained of shortness of breath, especially on exertion. No history of fever or chills. No history of infectious disease exposure or ill contacts. The patient has a history of tobacco use for many years. The patient denied any abdominal pain, nausea, vomiting or diarrhea.
PAST MEDICAL AND SURGICAL HISTORY: Depression, anxiety, and hepatitis C.
CURRENT MEDICATIONS: The patient is taking no medications.
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: The patient smokes cigarettes and drinks beer every day.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: No other positive pertinents reported by the patient beside information provided above.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99, pulse 70, respiratory rate 18, blood pressure 116/74, and saturations 100%.
HEENT: Normocephalic and anicteric. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact.
LUNGS: Diminished breath sounds with crackles at the right base.
HEART: Normal S1 and S2. No S3, S4. No murmur, gallop or regurgitation.
ABDOMEN: Soft and nontender. Nondistended. Positive bowel sounds.
EXTREMITIES: No clubbing or cyanosis.
NEUROLOGIC: The patient is awake, alert, and oriented x3. Cranial nerves are grossly intact. No focal deficits.
INITIAL LABORATORY FINDINGS: WBC 9.6, hemoglobin 12.4, hematocrit 36.2, and platelets 58. Sodium 134, potassium 4.6, chloride 106, bicarbonate 21, glucose 88. INR 1.5.
DIAGNOSTIC DATA: Chest x-ray showed right lower lobe pneumonia; however, CT scan of the chest show left upper lobe density compatible with infectious versus malignancy.
ASSESSMENT AND PLAN:
1. Left upper lobe lung mass, rule out infectious etiology versus malignancy.
2. Tobacco use.
3. Anxiety.
4. History of hepatitis C.
PLAN: We will follow the patient’s platelets and possible CT-guided biopsy of the lung mass to evaluate for infectious disease versus malignancy. We will continue to follow the patient closely.
