DATE OF CONSULTATION: MM/DD/YYYY
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.
