DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Colonic mass/tumor.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who came in with complaint of lower back pain. During his workup, the patient was found to have low hemoglobin and hematocrit of 8.8 and 28.4. Workup for anemia included colonoscopy performed. During colonoscopy, the patient was found to have a tumor at the ileocecal valve. Pathology of the tumor is pending.
PAST MEDICAL HISTORY: Significant for hypertension, diabetes, history of coronary artery disease and MI in the past. Also, past medical history is significant for hypercholesterolemia and hypothyroidism.
PAST SURGICAL HISTORY: Significant for stent placement.
MEDICATIONS: Aspirin, Advair, insulin, hydrochlorothiazide, lisinopril, Singulair, Synthroid, ranitidine and Zocor.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Noncontributory.
FAMILY HISTORY: Significant for hypertension, diabetes and CVA.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2 degrees, pulse 76, respirations 18, blood pressure 130/66, and O2 saturation 93%.
HEENT: Examination within normal limits.
CARDIOPULMONARY: Examination within normal limits.
ABDOMEN: Soft, nontender and nondistended. No evidence of hernias or hepatosplenomegaly. Presence of insulin pump was noted in the right lower quadrant.
EXTREMITIES: Examination within normal limits.
LABORATORY DATA: These include CMP revealing sodium 140, potassium 4.2, chloride 106, CO2 of 26, glucose 178, BUN 23, creatinine 1.5, total bilirubin 0.3, alkaline phosphatase 90, ALT 22, and AST 26. CBC on admission revealed hemoglobin of 8.8, hematocrit of 28.4, white cell count 4.8, and platelet count of 394,000.
RADIOLOGICAL DATA: Radiological investigation included lumbar spinal films, four views, and no evidence of acute fracture or acute pathology identified.
ASSESSMENT AND PLAN: This is a (XX)-year-old gentleman who appears to have a tumor located at the ileocecal valve region. Pathology of the tumor is pending. Irrespective of the pathology, the patient would need right hemicolectomy. We have discussed this case in detail with the patient and the patient’s wife. They would like to proceed with this operation during this hospitalization. Before we proceed with the operation, we would like to obtain a CT scan of the abdomen and pelvis and also would request a CEA level on this patient. This patient has significant cardiac history and needs to be evaluated by a cardiologist prior to proceeding with elective major abdominal operation.
