DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation for limited small cell lung cancer.
I was asked to see this patient by Dr. Doe for radiation oncology evaluation for his limited small cell lung cancer. He was seen today in consultation in the radiation therapy department.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old smoker with COPD presented with increased shortness of breath and was found to have a large right paratracheal mass. CT-guided biopsy done last year showed small cell lung cancer. The patient’s workup included a PET scan done last year, which showed disease limited to the chest.
The patient was treated with 4 cycles of VP-16 and carboplatin with good response, and a repeat chest CT done earlier this month showed significant reduction of the tumor in the chest. CT of the abdomen and pelvis done last week showed no tumor in the abdomen and no change of the right hepatic cyst and the left renal cyst.
The patient was admitted yesterday after developing acute shortness of breath, being exposed to secondhand smoke. The patient’s condition is much improved since admission.
PAST MEDICAL HISTORY: COPD and congestive heart failure.
PAST SURGICAL HISTORY: Right carpal tunnel surgery, spinal laminectomy and fusion.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient is married. He smoked up to 3 packs a day for many years up until the time of the diagnosis of his cancer.
REVIEW OF SYSTEMS: CONSTITUTIONAL: Weight loss of about 15 pounds in the last month. HEENT: Eyes: Good vision. Ear, Nose, and Throat: Unremarkable. CARDIOVASCULAR: As per history. RESPIRATORY: Chronic smoker’s cough. No longer has significant shortness of breath, although remains on oxygen. GASTROINTESTINAL: No constipation or diarrhea. GENITOURINARY: No bladder dysfunction. SKIN: No skin rash. NEUROLOGIC: No numbness or weakness. ENDOCRINE: No diabetes. LYMPHATICS: Large, firm mediastinal lymphadenopathy, which has reduced in size. MUSCULOSKELETAL: History of back surgery.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 130 pounds.
GENERAL APPEARANCE: The patient is in no acute distress.
HEENT: The head is normocephalic. The oral cavity is clean.
NECK: No neck masses.
LUNGS: Symmetrical. Some rhonchi, more on the right.
HEART: Regular without murmurs.
ABDOMEN: Benign without palpable masses or organomegaly.
EXTREMITIES: No edema.
NEUROLOGIC: No obvious focal neurologic signs.
LYMPHATICS: No peripheral lymphadenopathy.
MUSCULOSKELETAL: No bone tenderness.
LABORATORY DATA: WBC 19.4, hemoglobin 9.2, platelets 238. Chemistry: BUN 26, creatinine 1.1, calcium 8.4. Labs from yesterday show BUN 9, creatinine 1.3, calcium 8.6. WBC 11.7, hemoglobin 10.2, platelets 454.
ASSESSMENT: The patient is a (XX)-year-old man with limited stage small cell lung cancer with a large right paratracheal mass, which has reduced in size significantly after 4 cycles of chemotherapy.
RECOMMENDATIONS: The patient is a candidate for consolidation radiation therapy, perhaps with further chemotherapy. At this point, he was counseled about the nature, potential side effects and complications of treatment and will undergo a simulation today. Treatment will be initiated within the next week. About 40 Gy will be delivered to the mediastinum.
Thank you for the opportunity of evaluating the patient. We will follow along with you.
