DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

DIAGNOSES:

1. Malignancy of the bronchial lung.
2. Pleural effusion.
3. Metastatic malignancy to the liver.
4. Ascites.
5. Chronic airway obstruction.
6. Anemia.
7. Diabetes.
8. History of tobacco use.

PROCEDURES DURING THIS ADMISSION: Percutaneous abdominal drainage and injection of chemotherapy.

HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old gentleman with history of a small cell lung cancer treated with both chemotherapy and radiation. He had been in stable condition as of late until about one month ago when he started to develop symptoms of increasing shortness of breath. This has been associated with swelling in his lower extremities as well as development of jaundice.

He presented to the emergency department where he was noted to have a right upper lobe infiltrate and a new right pleural effusion. For that, he was admitted for further evaluation and treatment. Also, complains upon admission of decreased appetite and constipation.

HOSPITAL COURSE: After assessment in the emergency department, the patient was admitted and placed on IV fluids. Labs were obtained, and consult was made to the pulmonary specialist regarding the patient’s diagnoses of lung CA and pneumonia. The patient was placed on the community-acquired pneumonia protocol and treated with IV antibiotics. For management of his diabetes, a consult was made to the endocrine specialist, and he was maintained on nutritional therapy, Accu-Chek monitoring, insulin therapy with evaluation of TSH and hemoglobin A1c. A consult was made to the pulmonary specialist regarding his pleural effusion and shortness of breath. After assessment and evaluation, recommendation was for ultrasound-guided thoracentesis, evaluation of the abdomen for ascites, and oxygen to keep saturation greater than 93%.

On MM/DD/YYYY, the patient also underwent evaluation by bilateral venous Doppler of the lower extremities with no evidence of deep vein thrombosis of the right or left leg noted. He also underwent evaluation for dyspnea with a 2-dimensional echocardiogram. This revealed concentric left ventricular hypertrophy present with normal left ventricular systolic function noted. Abnormal diastolic compliance was seen. No pericardial effusion was noted.

The patient underwent ultrasound-guided paracentesis for his diagnosis of ascites and successful paracentesis was done with removal of about 250 mL of bloody ascitic fluid. CT scan of the brain obtained on MM/DD/YYYY revealed no acute intracranial pathology identified. Current scan appears similar to that of previous done almost 10 months ago. Ultrasound of the chest was ordered with regard to pleural effusion. Ultrasound revealed a small right pleural effusion present. Despite removal of fluid, the patient continued to have dyspnea and shortness of breath.

Discussion was made with the patient and his family with regard to his current condition and overall poor prognosis. He was treated in the past with both chemotherapy and radiation and now presents with pleural effusion and ascites with associated jaundice. The patient was made a DNR with full active treatment and was in agreement to single-agent chemotherapy for salvage chemotherapy. The patient was then treated with single-agent irinotecan (CPT-11), but despite treatment, he continued to have jaundice, elevated bilirubin, and progressive metastatic disease to the liver.

Discussion was made with both the patient and his wife with regard to discharge planning and hospice care. It was the wish of the patient that he return to home to be cared for by family and for hospice consult to be obtained. Social work was consulted with regard to arranging hospice care at home. Once these arrangements were completed and necessary equipment obtained, the patient was then discharged to home under the care of hospice. We will continue to monitor him closely while under the care of hospice at home.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Myelodysplastic syndrome and pancytopenia.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old man diagnosed with myelodysplastic syndrome several months ago when he presented with progressive pancytopenia. We have followed him in the office, and unfortunately, despite supportive care with Procrit and intermittent transfusions, his pancytopenia has worsened over time. He has had several hospitalizations for congestive heart failure due to ischemic cardiomyopathy. He is now admitted for right upper extremity cellulitis versus gout versus pseudogout. Since admission, he has undergone treatment with antibiotics and has received transfusion of packed RBCs. The patient continues on weekly Procrit.

PAST MEDICAL HISTORY: As above, atrial fibrillation, chronic renal insufficiency, hyperlipidemia, coronary artery disease, hypertension, ischemic cardiomyopathy, and lumbar stenosis.

SOCIAL HISTORY: The patient is divorced. Smoking: None currently. Alcohol: None.

FAMILY HISTORY: No malignancy.

REVIEW OF SYSTEMS: Positive for chronic shortness of breath, profound weakness, anorexia, fatigue and an itching rash, which is gradually resolving.

PHYSICAL EXAMINATION:
GENERAL: The patient is a frail man, in no acute distress.
VITAL SIGNS: Temperature 97.4, pulse 94 and regular, respirations 16, and blood pressure 120/52.
HEENT: Normocephalic and atraumatic. Oral mucosa is moist.
NECK: Lymph nodes. No palpable supraclavicular, infraclavicular, cervical, axillary, inguinal adenopathy.
HEART: Irregularly irregular.
LUNGS: There are crackles at the bases bilaterally.
ABDOMEN: Bowel sounds are present. The abdomen is soft and nontender without organomegaly.
GENITALIA: Normal external male genitalia.
NEUROLOGIC: No focal deficit.
HEMATOLOGIC: Scattered ecchymosis.
SKIN: Resolving rash on the back, peeling skin on the right hand at the site of previous swelling. Significant for pallor. There is no jaundice.

LABORATORY DATA: BUN 56 and creatinine 1.5. White blood cell count 28,000, hemoglobin 7.2, hematocrit 24.4, and platelets 32,000.

ASSESSMENT:
1.  Myelodysplastic syndrome with worsening pancytopenia. The patient has declined low intensity chemotherapy. We are continuing supportive care with Procrit and transfusions to attempt to keep hemoglobin greater than 7.5.
2.  Ischemic cardiomyopathy.
3.  Rash, resolving.
4.  Right hand cellulitis, improving.
5.  Chronic renal insufficiency.
6.  Coronary artery disease.

RECOMMENDATIONS:  Continue weekly Procrit and transfuse to keep hemoglobin greater than 7.5. Follow up with us next week. Unfortunately, this gentleman’s prognosis is poor. He would be an inappropriate patient for hospice care. His daughter has durable power of attorney for health care. The patient seems to understand the seriousness of his multiple medical problems at this time.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old with myelodysplastic syndrome, on Neupogen and Aranesp. The patient is having terrible, terrible pain in his neck, which he has injured in the past.

REVIEW OF SYSTEMS: LUNGS: Unremarkable. CARDIOLOGY: Unremarkable. GI: Unremarkable. GU: Unremarkable. MUSCULOSKELETAL: Bad neck and back pain, which was chronic. NEUROLOGIC: No new motor deficits. PSYCHOLOGIC: Unremarkable. HEMATOLOGY: Unremarkable.

PHYSICAL EXAMINATION: VITAL SIGNS: Height 66, weight 190 pounds, temp 97.6 degrees, blood pressure 142/72, pulse 74, and respiratory rate 16. HEENT: Eyes: Unremarkable. HEART: Unremarkable. ABDOMEN: Unremarkable. EXTREMITIES: Unremarkable. MUSCULOSKELETAL: Tenderness in the neck area and the muscles are tight in the shoulder area. There is no significant neuro or motor deficit. SKIN: Unremarkable. HEMATOLOGIC: Unremarkable.

LABORATORY STUDIES: Hemoglobin 10.6. WBC count 3.8.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old with myelodysplastic syndrome.
1.  Thrombocytopenia. Platelet count is 239, normal.
2.  Leukopenia. ANC 2.7, WBC count 3.8.
3.  Anemia. Hemoglobin 7. The patient on Aranesp.
4.  Severe night pain. He received Neupogen and Aranesp. We are going to send him for pain management first before giving him more Neupogen. According to the patient, he got deathly sick with severe neck pain.
5.  We will discontinue Neupogen and will give him Leukine.
6.  The patient to see Dr. John Doe as soon as possible.

Hematology Oncology Sample #2

PRINCIPAL DIAGNOSIS: Bone marrow involvement, T-cell lymphoproliferative disorder.

RADIOGRAPHIC STUDY: CT scan of chest, abdomen and pelvis done did not reveal any adenopathy or any masses. She does have a solitary gallstone and renal cortical cyst. Otherwise, unremarkable scan.

INTERMITTENT HISTORY: The patient is here for her six-month followup. Since the last visit, she had back pain and she had fractured vertebrae. She was evaluated at the outside hospital and had kyphoplasty. Also, just a couple of days ago, she was standing on a small stool in her kitchen to reach for an object in the cabinet, she fell backward and she fractured her right arm. There is an x-ray from outside hospital; it showed impacted fracture of the radial neck. She did see Orthopedics.

REVIEW OF SYSTEMS: Her appetite is good. There is no weight loss or loss of appetite. No fever or night sweats. No frequent infection. Her energy is slow, but she said now with the weather, it is getting better. She is not having any fever or night sweats. No unusual headache, difficulty swallowing, chest pain or shortness of breath. No abdominal pain. She does have a bruise from her fall but otherwise no significant changes. The remaining review of systems was completely unremarkable.

PHYSICAL EXAMINATION: GENERAL: She is awake, alert, and oriented. VITAL SIGNS: Stable. HEENT: Within normal limits. There is no lymphadenopathy in the cervical, supraclavicular, axillary or inguinal area. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. ABDOMEN: No organomegaly. EXTREMITIES: Lower extremities: No edema. Upper extremities: She does have some bruises on her right arm, and she has a splint on her right arm. NEUROLOGIC: Examination was intact.

ASSESSMENT AND PLAN: The patient is a pleasant (XX)-year-old Hispanic female with a T-cell lymphoproliferative disorder manifested as large granular lymphocyte leukemia classified as T-cell lymphoproliferation. She does not have any involvement in any of her lymph glands. The CT scan that she had did not reveal any masses or adenopathy. Her skin inspection did not reveal any skin lesions. Today, we will repeat her CBC and see if the counts are stable. We will also review her peripheral blood smear. If the counts are stable, then we will continue to observe her and we will see her in follow up in six months from now.

Hematology Oncology Sample #3

PRINCIPAL DIAGNOSES:
1.  Follicular lymphoma removed from the small intestine.
2.  Abnormal PET scan showed activity in the duodenum, right supraclavicular area, and right parotid area.

RECENT PROCEDURES:  Upper endoscopy and biopsy of the duodenum was completely normal.

INTERIM HISTORY:  The patient is here for a followup visit after she got the PET scan, which showed the activity in the right parotid gland and the right supraclavicular area and the duodenum. She had gone through the upper GI evaluation and the upper endoscopy was completely normal, and the biopsy did not reveal any evidence of lymphoma. We asked her to come for a followup. When we did examine her before, we were not able at that time to feel any lymph node in the right supraclavicular area and that was back in February. She came today. She is feeling well and does not have any specific complaint or problem. No unusual headache. No difficulty swallowing, chest pain, or shortness of breath. No abdominal pain. No fever or night sweats. No weight loss or loss of appetite, but she said for the last week or so, she noted the development of the mass in the right supraclavicular area.

PHYSICAL EXAMINATION: GENERAL: She is awake, alert, and oriented. VITAL SIGNS: Stable. HEENT: Within normal limit. Normocephalic and atraumatic head. The pupils are equal in size. LYMPH NODES: She does indeed have a new lymph node that appeared in the right supraclavicular area; it is around 2 x 3 cm. We did not appreciate any other lymphadenopathy. ABDOMEN: Soft, no palpable masses. No organomegaly. HEART: Regular rhythm. LUNGS: Clear to auscultation and percussion. EXTREMITIES: Lower extremities: No edema. MUSCULOSKELETAL: Unremarkable. SKIN: Unremarkable.

ASSESSMENT AND PLAN:  The patient is a pleasant lady who had small bowel obstruction today due to follicular lymphoma. Now, she has a sudden onset of lymph node in the right supraclavicular area. It is most likely consistent with lymphoma, but we would like to see if it is the same type as her follicular lymphoma or if it is an aggressive type. Definitely, we need to remove the right supraclavicular lymph node and she is going to see Dr. John Doe for this, and based on the pathology, then we would determine the appropriate treatment that is needed. The fact that this lymph node appeared quickly, tells us we need to address the treatment with the systemic therapy. So, this will be done after the lymph node is removed. The above was discussed in detail with the patient and she is in agreement with it.

CHIEF COMPLAINT: Sickle cell beta plus thalassemia.

INTERVAL HISTORY: The patient returns to the pediatric hematology/oncology clinic for followup. Since the last clinic visit, the family has moved. The patient comes accompanied by his foster mother and foster father. The patient is now a (XX)-month-old boy with diagnosis of sickle cell beta plus thalassemia. His hemoglobin electrophoresis six months ago showed a hemoglobin S of 47%, hemoglobin F of 32%, hemoglobin A of 17%.

The patient has been asymptomatic since his last clinic visit six months ago. However, foster mother says that at times he complains of lower extremity pain, which apparently improves with just massage. He has not been hospitalized for vaso-occlusive pain crisis or any other sickle cell disease related complications. The patient is an oral breather. He snores at night and has frequent congestion despite his Claritin.

REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, weight loss or other constitutional symptoms.
SKIN: No rashes, petechiae, bruising or eczema.
HEENT: No vision or hearing problems. No nasal congestion or epistaxis. No mouth pain or difficulty swallowing.
RESPIRATORY: No cough, congestion or difficulty breathing.
CARDIOVASCULAR: No history of heart disease.
GASTROINTESTINAL: No nausea, vomiting, diarrhea, constipation, melena or hematochezia.
GENITOURINARY: No hematuria or dysuria.
MUSCULOSKELETAL: No joint pain or dactylitis.
NEUROLOGIC: Normal developmental milestones.
HEMATOLOGIC: History of sickle cell beta plus thalassemia.

MEDICATIONS:
1.  Claritin 5 mg p.o. once a day.
2.  Albuterol sulfate HFA 90 mcg inhaler 1-2 inhalations every 4-6 hours as needed for wheezing.
3.  Nasonex 50 mcg spray 2 sprays intranasally every day.

PHYSICAL EXAMINATION:
GENERAL: The patient is alert, happy, in no distress. He is cooperative during the examination.
VITAL SIGNS: Temperature 97.8, pulse 142, respirations 26, blood pressure 110/70, weight 13.2 kg (25th percentile), height 89.6 cm (25th percentile), and oxygen saturation 100% on room air.
SKIN: No paleness, rashes, petechiae or bruising.
HEENT: Normocephalic. Pupils are equally round and reactive. Extraocular muscles are intact. Conjunctivae are clear. Tympanic membranes are pearly gray. Oropharynx is pink and moist. Tonsils are generous for his age, but there is no exudate. His nares seemed congested. There is oral breathing.
LYMPHATICS: No palpably enlarged nodes in the neck, axillae or groin.
CHEST: Clear to auscultation throughout.
HEART: Regular rate and rhythm without murmurs.
ABDOMEN: Soft and benign without organomegaly or masses.
EXTREMITIES: Warm and well perfused without cyanosis or edema.
NEUROLOGIC: Nonfocal.

IMPRESSION:
1.  The patient is a (XX)-month-old boy with sickle cell beta plus thalassemia.
2.  Hereditary persistence of hemoglobin F.
3.  Seasonal allergies with what appears to be chronic rhinitis and probably inflammation of tonsils and adenoids with obstructed nasal breathing.

PLAN:
1.  Today, we recommended to the family to schedule an appointment with Dr. Jane Doe to discuss the fact that he probably has congested upper airways. He may need further treatment with Flonase and referral to ENT for further evaluation. Dr. Jane Doe may need to consider the possibility of referring him for a sleep study after evaluation from ENT to determine whether he has impaired sleep secondary to nasal obstruction.
2.  Regarding his blood work, at the family’s request, we decided not to proceed with further testing. His H&H recently was 11.9. His hemoglobin was 11.9 a couple of weeks ago.
3.  The family has recently moved. We would like to refer him back for ongoing care.
4.  At this point, we think it will be reasonable to continue to monitor his reactive airway disease, but we would recommend referral to pediatric pulmonology if his condition does not improve.
5.  The family knows to call or return if his condition worsens in any way.
6.  For his lower extremity pain that appears only intermittently, we have suggested the family to give ibuprofen 100 mg/5 mL, 7.5 mL every 8 hours as needed for pain. If that does not improve and he continues to experience pain, he may benefit from treatment with hydrocodone.
7.  The family knows to call or return if his condition worsens in any way.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Metastatic non-small cell lung cancer.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic woman with multiple medical problems, who presented with increasing shortness of breath, orthopnea and paroxysmal nocturnal dyspnea. She was suspected of having an effusion and was referred for emergency assessment. She was found to have a large left-sided pleural effusion and was admitted for further evaluation and therapy.

Her hospital course has been notable for CT scan of the chest revealing multiple pulmonary nodules, left and right lung, with the largest being on the left side in the upper lung fields. She had an associated large left-sided pleural effusion with associated atelectasis and compressive changes. Thoracentesis had been performed twice. The second time, it was performed today for relief of symptoms. She has had some improvement in her sense of dyspnea, but she requires oxygen therapy. A pleural fluid analysis was performed for sampling of pleural fluid four days ago. This revealed abnormal cells consistent with adenocarcinoma. This was CK7 positive, TTF-1 positive. Mammaglobin was negative. GCDFP-15 and cytokeratin 20 were also negative.

The patient does have a remote history of breast cancer but apparently of an early stage, treated with lumpectomy and radiation, and did not require adjuvant treatments. She has also had a history of thyroid malignancy, treated probably 25 years ago with a total thyroidectomy and radioactive iodine. She does not have any evidence of recurrent thyroid cancer since that time.

PAST MEDICAL HISTORY: Notable for chronic lung disease with asthmatic bronchitis. She has had a history of right-sided breast cancer, treated with lumpectomy and radiation therapy 10 years ago, apparently early stage, although we could not find the primary information. She has a history of thoracic aortic aneurysm that was repaired eight years ago. Again, we do not have the primary information available. Last year, she had an intracerebellar hemorrhage, midline, treated conservatively. During this time, she was also on anticoagulation. She also has underlying atrial fibrillation, of a chronic nature, was previously on Coumadin anticoagulation, presently on aspirin. She did not have Coumadin reinitiated after her intracerebellar hemorrhage. She also has a history of hypothyroidism, following the treatment for thyroid cancer, and hypertension.

PAST SURGICAL HISTORY: In addition to the right breast surgery, total thyroidectomy, bilateral hip arthroplasties, and bunion excision from both feet.

ALLERGIES: NKDA.

MEDICATIONS ON ADMISSION: Levothyroxine 0.5 mg daily, allopurinol 100 mg daily, potassium chloride 20 mEq daily, Toprol-XL 100 mg daily, lisinopril 10 mg daily, hydrochlorothiazide 12.5 mg daily, Celexa 20 mg daily and aspirin 81 mg daily.

FAMILY HISTORY: Notable for lung cancer in her brother, who recently passed away. Her brother was apparently a nonsmoker. However, no other family history of breast, lung, thyroid or other malignancies. Both of her parents have passed away. She has five children, apparently alive and in good health.

SOCIAL HISTORY: The patient is widowed and lives independently in an assisted care facility. She is a nonsmoker and has not smoked at all during her adult life. She was exposed to secondary smoke as a child. She does not drink alcohol. She is independent in activities of daily living.

REVIEW OF SYSTEMS:
CONSTITUTIONAL: Notable for stable weight. No recent change in activity, except with the recent physical activity with shortness of breath. She has noted some fatigue over the past week or two.
HEENT: No vision or hearing loss.
RESPIRATORY: Notable for shortness of breath as noted.
CARDIOVASCULAR: No chest pain or palpitations.
GASTROINTESTINAL: No altered bowel pattern, melena or hematochezia.
GENITOURINARY: No dysuria, hematuria or frequency.
MUSCULOSKELETAL: No arthritis or arthralgias. Her hip arthroplasties are functioning well.
SKIN: Without unusual rashes.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 112/76 with a pulse of 82, temperature 98.8. She is on nasal cannula oxygen with O2 saturation 98% on 2 liters.
HEENT: Normocephalic, atraumatic head. Pupils are reactive. She has oxygen delivered by nasal cannula. The oropharynx shows no mucosal lesions.
NECK: Supple.
LYMPH NODES: No obvious cervical, supraclavicular or axillary nodes.
LUNGS: Notable for decreased breath sounds bilaterally, could not definitely hear any rubs. She is dull throughout the left and right lung fields.
HEART: An irregularly irregular rhythm, soft early systolic flow murmur. No diastolic component. There is no significant jugular venous distention.
ABDOMEN: Soft and nontender. There is no clearly palpable liver or spleen.
EXTREMITIES: No clubbing, cyanosis or edema. She does have bilateral hip scars consistent with her arthroplasties.
SKIN: Notable for no significant rashes or cutaneous lesions.

LABORATORY DATA: CBC showed white count yesterday of 7500, hemoglobin 12.2 and platelet count 178,000. This is not appreciably different from her admission studies. Her BUN was 25 and creatinine was 1.1. She did not have any liver profile recently.

DIAGNOSTIC DATA: CT scan of the chest was reviewed and is notable for multiple spiculated nodules present in the right upper lobe, smaller nodules in the left upper lobe along with the largest nodule measuring about 2 cm in the left upper lobe. The liver, any area visualized, looks unremarkable. She has a large pleural effusion on the left as noted. Post thoracentesis today, chest x-ray still reveals a fairly sizable effusion.

IMPRESSION:
1. Poor prognosis, stage IV (T4NxM1) non-small cell lung carcinoma, adenocarcinoma (non-squamous).
2. History of cerebellar hemorrhage.
3. History of thoracic aortic aneurysm, repaired in the past.
4. History of right-sided breast cancer, apparently early stage, status post lumpectomy in the past, followed by radiation therapy.
5. Remote history of thyroid cancer, 25 years or more ago, treated with thyroidectomy and radioactive iodine.

This patient is currently with symptomatic pleural effusion and had a declining performance status. She has mild anorexia and multiple other medical problems, which do not appear to be acutely impairing her. Her overall prognosis with respect to the lung cancer is obviously quite poor, as this is an incurable process. We may be able to control the disease for a reasonable period of time through use of chemotherapy or through use of the EGFR inhibitor, erlotinib. As a nonsmoking Hispanic woman with adenocarcinoma, she actually may have a reasonably high chance of response to erlotinib. Further investigation for EGFR mutation would also be predictive of the likelihood of response. In fact, if we could document EGFR mutation, she may be more likely to benefit from the targeted therapy than chemotherapy. At this point, however, we will need to deal with a number of issues. Presently, insurance coverage of erlotinib depends on previous treatment with chemotherapy, i. e. erlotinib as a second-hand agent. We may be able to negotiate with the insurance companies if we could prove EGFR mutation. Secondly, however, is the uncertainty of the drug coverage that she may have, which may make the erlotinib unaffordable if she does not have appropriate insurance coverage. At this point, however, the patient is also uncertain as to whether she wishes to pursue therapy. She would like to discuss this with her daughter. Things to consider would include transportation for chemotherapy and/or insurance coverage for agents such as erlotinib. In addition, given the remote history of thyroid cancer, we should also check for this possibility, and this could be screened with a thyroglobulin assessment. Finally, it may be worthwhile also looking at a baseline bone scan to see whether she has any potential long bone involvement that could result in compromise in the near future.

RECOMMENDATIONS:
1. Although thoracentesis has been successful, long term she may be better treated with a pleural drainage catheter with subsequent pleurodesis.
2. As an outpatient, she can consider chemotherapy versus erlotinib.
3. We will make arrangements for a baseline bone scan.
4. We will also check the thyroglobulin level and CEA.
5. We will investigate whether the pathology department can run EGFR mutational analysis on the samples of tissue that they have available.

Thank you very much for the opportunity to participate in her care. We will continue to follow up along with you.

REQUESTING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Neutropenia and thrombocytopenia.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with past medical history significant for hepatitis C virus infection, status post peginterferon therapy a long time ago, status post prednisone treatment which led to exacerbation of his hepatitis C and ultimately was not deemed to be of any benefit. The patient underwent a total hip arthroplasty three years ago and at that time received a course of intravenous gamma globulin without any benefit in terms of raising the platelet count. The patient received platelet transfusion and ultimately went through the surgery. The patient was seen in the attending physician’s office yesterday and was found to have some erythema involving the left hip region, which is the site of the left total hip arthroplasty, and since concerns for cellulitis were raised, the patient was admitted for intravenous antibiotic therapy.

Upon admission, the patient was found to have neutropenia with an absolute neutrophil count of 1300. The patient’s ANC was 1000. The patient’s platelet count has also been low. It was 25,000 on admission and then subsequently, today, was 23,000. Hematology consultation was requested in light of these findings. Upon reviewing the old records, the patient’s platelet count back about three years ago was in the same range at 22,000 and then subsequently at 30,000. The patient had neutropenia in the past as well with a white blood cell count that was close to 3000. The patient denies having any bleeding complications. At this point in time, the patient denies having any fevers.

PAST MEDICAL HISTORY:  As above.

PAST SURGICAL HISTORY:  As above.

PHYSICAL EXAMINATION:  The patient is sitting in the chair and appears to be in no acute distress. Vital signs are stable, afebrile. Head is normocephalic and atraumatic. Pupils are equal, round, and reacting to light. Neck is supple. No JVD. Chest is clear to auscultation. Heart has S1 and S2. Abdomen is soft and nontender. On neurologic exam, no gross neuro deficits. On examination of the extremities, the patient has an area of erythema involving the left posterior hip region at the site of the scar for left total hip arthroplasty.

LABORATORY DATA:  WBC count of 2.18 with an absolute neutrophil count of 1000, hemoglobin of 15.2, hematocrit of 44.4, and platelet count of 23,000. PTT 29. INR 1.32. Sodium 134, potassium 4.2, chloride 102, carbon dioxide 26, glucose 110, BUN 10, creatinine 0.8, calcium 8.6, total bilirubin 3.2, alkaline phosphatase 112, ALT 49, and AST 40.

IMPRESSION:  Hepatitis C virus infection, likely leading to hypersplenism and subsequently causing neutropenia and thrombocytopenia. We agree with Dr. John Doe that etiology for thrombocytopenia is likely splenic sequestration. The patient has had a trial of intravenous gamma globulins and steroids without any benefit from both these modalities in the past.

RECOMMENDATIONS:  Since the patient’s absolute neutrophil count is 1000, we would not recommend any cytokine support at this point in time. Should the absolute neutrophil count drop below 1000, then we would recommend Neupogen 300 mcg subcutaneously daily x2 days. The patient is not bleeding at this time and is in no need of any platelet transfusions. Over the years, the patient’s platelet count has not changed significantly and as such is in no need of any hematologic intervention.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Pancytopenia.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who recently was admitted for treatment of alcohol withdrawal. His laboratory studies were significant for pancytopenia. The patient has a history of heavy cigarette use, heavy alcohol abuse, and also illicit drug use when available to him. He admitted himself for treatment of delirium tremens as he has had them in the past and recognizes the symptoms. His CBC today showed a white count of 3.4, hemoglobin 10.8, hematocrit 31.8, and platelet count was 68,000. The patient has also undergone ultrasound of his abdomen, and the results are pending.

PAST MEDICAL HISTORY: Significant for hepatitis B and C, history of alcohol withdrawal and delirium tremens, history of MRSA infection to chronic open wound.

PAST SURGICAL HISTORY: None.

ALLERGIES: No known allergies.

CURRENT MEDICATIONS: None.

SOCIAL HISTORY: The patient smoked approximately 1 pack per day for the last 30 years. He drinks approximately 1 case of beer a day and has had none in the last 4 days. He also admits to illicit drug use when it is available to him.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: The patient reports no fevers, night sweats or chills. No recent weight loss or gain. No change in vision or blurred vision. No chest pain or palpitations. No dizziness. No shortness of breath. No abdominal pain. No nausea, vomiting or diarrhea. No hematochezia or melena. No dysuria or hematuria. No focal weakness. No new skin lesions. He does have multiple open wounds on his bilateral hands and multiple scabbed wounds, which are chronic.

PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented x3, in no acute distress. He is noted to have very poor hygiene.
VITAL SIGNS: Blood pressure 122/66, pulse 96, respiratory rate 16, and temperature 98.6.
HEENT: Large cyst to the right and left naris, otherwise unremarkable.
HEART: Regular rate and rhythm.
LUNGS: Diminished to auscultation throughout and clear.
ABDOMEN: Soft and nontender. Bowel sounds are present.
EXTREMITIES: Symmetrical. Normal strength bilaterally. Pulses are palpable. No edema, clubbing or cyanosis.

IMPRESSION:
1. Pancytopenia, possibly secondary to chronic liver disease, alcohol abuse or viral etiology such as human immunodeficiency virus or possible primary bone marrow disorder.
2. History of hepatitis B and C.
3. Chronic open wound of his bilateral hands and right buttock with history of methicillin-resistant Staphylococcus aureus infection.
4. Urinary tract infection.
5. Chronic obstructive pulmonary disease.
6. Alcohol withdrawal, currently under CIWA protocol.

RECOMMENDATIONS: At this time, we will go ahead and order laboratory studies to assess for nutritional deficiencies as well as just check reticulocyte count and platelet antibodies. HIV results are pending as well as abdominal ultrasound. Pending results of his laboratory studies, we will make further recommendations to include possible bone marrow biopsy if primary bone marrow disorder is suspected.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Sickle cell disease.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male admitted for evaluation of chest pain and dizziness. The patient was recently hospitalized less than one week ago for evaluation and treatment of dizziness and vertigo. He now presents with chest pain, specifically left and right chest pain, in the area of the costophrenic angles. The patient states he has had this pain for approximately the last five days with no improvement. He is also complaining of persistent dizziness as well. He recently had a CT of the chest. It did show some bilateral pleural thickening and either scarring or atelectatic changes in the right middle lobe, lower lobe, and lingula. The patient also has a fever of 102 degrees and has been started on antibiotics empirically with Zosyn. He is also currently undergoing ultrasound of the chest to rule out pericardial effusion.

PAST MEDICAL HISTORY: Significant for sickle cell disease.

PAST SURGICAL HISTORY: None.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient is divorced. He reports no cigarette use. No ETOH.

ALLERGIES: No known allergies.

CURRENT MEDICATIONS: Includes folic acid 1 mg p.o. daily as well as oxycodone p.r.n. pain.

REVIEW OF SYSTEMS: The patient reports no recent weight loss. He has been febrile within the last 24 hours. He reports no loss of appetite. He complains of bilateral chest pain, worse with movement and deep inspiration. He complains of shortness of breath with exertion, and dizziness. No headaches. No palpitations. No abdominal pain. No nausea, vomiting or diarrhea. No dysuria or hematuria. No focal weakness. No new skin rashes or lesions.

PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented x3, in no acute distress.
VITAL SIGNS: Blood pressure 128/54, pulse 102, respiratory rate 18, and temperature 102.4 degrees.
HEENT: Unremarkable.
NECK: Supple. No lymphadenopathy.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation throughout.
ABDOMEN: Soft and nontender. Bowel sounds are present.
EXTREMITIES: Symmetrical. Normal strength bilaterally. Pulses are palpable. No edema, clubbing or cyanosis.

LABORATORY DATA: CBC today shows white count 13.8, hemoglobin 7.6, hematocrit 21.2, and platelets 262,000. MCV 80, ANC 7.2, creatinine 0.5, bilirubin 2.6, AST 66, and D-dimer 1.24.

IMPRESSION:
1. Sickle cell disease.
2. Chest pain, possibly secondary to pain crisis, pneumonia, or cardiac origin. CT of the chest was significant for bilateral pleural thickening.
3. Leukocytosis. The patient was started on IV Zosyn empirically for treatment of pneumonia.
4. Microcytic anemia.

RECOMMENDATIONS: At this time, we would recommend transfusing with 2 units of PRBCs, as the patient appears to be symptomatic secondary to his anemia with complaints of chest pain, dizziness, and shortness of breath but agree with 2-D echocardiogram for further evaluation of chest pain. Also, agree with empiric antibiotic treatment at this time.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Elevated total protein level and suspicion for plasma cell dyscrasia.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with a past medical history significant for hypertension, who was admitted to the hospital due to failure of outpatient antibiotic therapy since the patient had pneumonia. Upon admission, the patient was found to have an elevated total protein level at 8.6 with an elevated globulin fraction, and as such, suspicion for plasma cell dyscrasia was raised, and Hematology consultation was called. Upon interviewing the patient further, he denies having any other problems, except for some mild shortness of breath and coughing.

PAST MEDICAL HISTORY: As above and significant for hypertension and pneumonia, on outpatient antibiotic therapy in the form of Avelox.

ALLERGIES: None.

SOCIAL HISTORY: The patient denies smoking or abusing alcohol.

FAMILY HISTORY: Significant for breast cancer in mother and lung cancer in father, but father was a smoker.

PHYSICAL EXAMINATION:
GENERAL: The patient is sitting in bed, appears to be in no acute distress.
VITAL SIGNS: Stable. Afebrile.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reacting to light.
NECK: Supple. No JVD.
CHEST: Clear to auscultation.
HEART: S1 and S2.
ABDOMEN: Soft and nontender.
CNS: No neurological deficits.

LABORATORY DATA: WBC count 18,200, hemoglobin 12.4, hematocrit 36.4, and platelet count 366,000. Sodium 134, potassium 4.6, chloride 106, carbon dioxide 26, glucose 236, BUN 24, creatinine 1.44, calcium 8.9, total protein 7.8, albumin 2.8, globulin 5, total bilirubin 0.2, alkaline phosphatase 128, ALT 214, AST 60, amylase 72, lipase 300.

DIAGNOSTIC DATA: The patient underwent a V/Q scan, which was normal. Ultrasound of the gallbladder demonstrates a fatty infiltration of the liver and a right pleural effusion. Chest x-ray done demonstrates mild interval improvement in the right lower lobe consolidation. No pneumothorax was identified. The patient underwent serum protein electrophoresis, which did not demonstrate a monoclonal protein.

IMPRESSION: Elevated total proteins in a patient with pneumonia with serum protein electrophoresis demonstrating polyclonal hypergammaglobulinemia, most likely as a consequence of infection and inflammation. The patient likely does not have a plasma cell dyscrasia.

RECOMMENDATIONS: For completeness sake, we would obtain a serum immunofixation. Case was discussed at length with the patient, and he was made aware of these recommendations. The patient can be discharged from a hematology standpoint, and we would continue to follow him on an outpatient basis should he desire.

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Vaso-occlusive crisis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic male with recurrent vaso-occlusive crisis, who presents now with diffuse body pain reminiscent of his vasoocclusive crises. He stated that this started as a low-grade crisis-like pain. At that time, he experienced URI-type symptoms with low-grade fever. These symptoms are now resolving; however, his crisis has progressively gotten worse to 9-10/10. He has received Dilaudid 1 mg with minimal relief.

PAST MEDICAL HISTORY:  As noted above. Additionally, he has a history of MRSA discitis and recurrent port infections.

HOME MEDICATIONS:  Include methadone 10 mg q. 8 hours.

REVIEW OF SYSTEMS:  The patient is currently without the URI symptoms. He is having diffuse pain. No shortness of breath. No nausea or vomiting. He has a couple of skin lesions on his foot and leg that look like healed folliculitis on the leg and eczema on his foot.

PHYSICAL EXAMINATION:
GENERAL: He is well developed, well hydrated, alert and oriented x3.
HEENT: He has scleral icterus.
VITAL SIGNS: On presentation, he was afebrile, 122/72, 72, 12, and 99% on room air.
NECK: Supple. Thyroid is not palpable. No cervical or axillary adenopathy.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation.
ABDOMEN: Soft and nontender. Spleen is not palpable.
SKIN: Skin lesions as noted above.

LABORATORY DATA:  The patient’s hemoglobin is 7.2, WBC 7.6, and platelet count is 384. SGOT is mildly elevated at 48, bilirubin is 2.2, and creatinine is 0.6.

ASSESSMENT:  Recurrent vaso-occlusive crisis, rule out infectious etiology. Blood cultures will be assessed.

RECOMMENDATIONS:  We agree with placement of PICC line and have initiated a PCA pump. This may need to be dose escalated as the patient had high requirements for pain medications in the past. As mentioned, we will check blood cultures, and we will continue to follow him during the hospital stay. At this point, we would not transfuse the patient. We believe he may have a degree of transfusion hemosiderosis from a previous transfusion therapy.

Thank you very much for allowing us to participate in the care of this patient.