DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR REFERRAL: The patient is here for an abnormal CT scan of the thorax.
HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old gentleman with medical problems that are summarized below. He had a 2D echo that showed that he had a mean pulmonary artery pressure by estimation of 30, and subsequently, he had a CT scan for that as a workup of pulmonary hypertension. He then was noted to have two small lymph nodes, and pulmonary consultation has been requested. He has absolutely no pulmonary complaints. He has no dyspnea on exertion, chest pain or cough. He has no constitutional symptoms, fevers, chills or sweats. He lost weight, about 25 pounds, when he had knee surgery last year. He does snore, but he has no excessive daytime somnolence and fatigue or witnessed apneas. He has nasal polyps and occasionally has a dry mouth in the morning. He has a history of prostate carcinoma and is followed very closely for that. He had upper respiratory tract infections and pneumonia as a child, but he does not recall ever having histoplasmosis. He has no other swollen lymph nodes, and he generally feels quite well. His only complaint today is that he is having a little bit of nauseousness, and he does have a history of peptic ulcer disease. He has started back on Prilosec.
PAST MEDICAL HISTORY: Hypertension, CAD with MI years ago, non-insulin-dependent diabetes mellitus, DJD, GERD, prostate carcinoma and nasal polyps.
PAST SURGICAL HISTORY: Left knee replacement, left and right cataract surgeries and nasal polyp removal x2.
MEDICATIONS: Atenolol 50/25 daily, Prilosec p.r.n.
ALLERGIES: NKDA.
FAMILY HISTORY: Father deceased, 56, with cancer of unknown type. Mother deceased at 40 with cirrhosis.
SOCIAL HISTORY: The patient previously smoked two packs of cigarettes per day for 20 years, quit 15 years ago.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Negative.
HEENT: The patient has postnasal drip sometimes with nasal polyps, otherwise negative. He has a little bit of hearing problems.
GASTROINTESTINAL: Some nauseousness but no abdominal pain or any other complaints.
GENITOURINARY: Negative.
CARDIOPULMONARY: As in the HPI.
MUSCULOSKELETAL: Negative.
HEMATOLOGIC: Negative.
ENDOCRINE: Negative.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: This is a pleasant gentleman in no distress.
VITAL SIGNS: Weight 204, pulse 74, blood pressure 164/90, respiratory rate 18, and saturations on room air 96%.
HEENT: NC/AT. EOMI. PERRL. Conjunctivae are pink and anicteric. Nares are difficult to visualize. Oral cavity has a stage IV oropharynx with good dentition with no lesions or exudates. He has no appreciable axillary, supraclavicular or occipital adenopathy.
NECK: Supple without increased JVP, adenopathy or carotid bruits.
SKIN: Warm and dry.
HEART: PMI is not appreciated. Regular, S1 and S2 with a 3/6 systolic ejection murmur without radiation.
LUNGS: Symmetrical excursion, equal diaphragmatic descent. Clear to auscultation and percussion.
ABDOMEN: Soft and nontender. No appreciable HSM.
EXTREMITIES: Mild DJD with no C/C.
NEUROLOGIC: Grossly nonfocal.
DIAGNOSTIC DATA: Chest x-ray was not available. CT scan of the thorax shows a 1.4 cm precarinal lymph node with fatty hilum and a 1.2 cm paratracheal node. He also has a 3.2 mm subpleural nodule in the right apex and an ill-defined 12 mm density in the right upper lobe as well.
IMPRESSION: The patient has adenopathy in the chest, of uncertain clinical significance, with a small 3.2 mm subpleural nodule and an abnormal, ill-defined density in the right upper lobe superimposed on his diabetes mellitus, gastroesophageal reflux disease, coronary artery disease and medical problems as summarized above.
PLAN: At this point in time, he has no other symptoms, and he has no other adenopathy. We discussed with him PET scanning versus followup CT scan, and at this point in time, we will get a followup CT scan in four months and follow it then. They understand that this could be an early adenopathy related to some disease state or it could go away. The patient will call us if there is any change in his symptoms, and we will see him when his CT scan is done.
