DATE OF CONSULTATION: MM/DD/YYYY
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.
