DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Anemia.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old woman who was admitted to the hospital yesterday with worsening anemia. She has longstanding anemia felt to be secondary to a combination of iron deficiency, hemolysis, and anemia of chronic disease. She has been on oral iron therapy at home as well as Procrit injections. Despite all these measures, her hemoglobin was noted to be declining. She has not had any recent change in her bowel habits or seen any blood in her stool.
She denies anorexia, weight loss, nausea, vomiting or abdominal pain. She has a history of colon polyps and her last complete colonoscopy was eight years ago with diverticulosis and hemorrhoids but no polyps. She did have a flexible sigmoidoscopy three years ago that was significant only for hemorrhoids.
Her last EGD was eight years ago at which time she was noted to have small gastric polyps and duodenal diverticulum. Since being admitted to the hospital, she has been transfused one unit of blood. Her hemoglobin on admission was 6.6. A repeat hemoglobin is currently pending.
PAST MEDICAL HISTORY: As above, coronary artery disease, aortic stenosis, atrial fibrillation, anemia, mesenteric ischemia, hypertension, and hypercholesterolemia.
PAST SURGICAL HISTORY: CABG, mitral valve replacement, cataracts, carotid endarterectomy, rotator cuff surgery, surgery for ectopic pregnancy, hemorrhoidectomy, superior mesenteric artery stent, and exploratory laparotomy with lysis of adhesions.
ALLERGIES: Multiple, listed in the chart.
HOME MEDICATIONS: Atenolol, biotin, Coumadin, digoxin, FoliTab, Librium, Lipitor, magnesium oxide, Procrit, Protonix, Vasotec, and vitamin D.
SOCIAL HISTORY: Previous tobacco. No alcohol. No illicits.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS:
GENERAL: The patient denies fevers or chills.
HEENT: Denies vision problems or hearing problems.
CARDIOVASCULAR: Denies chest pain or irregular heartbeats.
RESPIRATORY: No cough, shortness of breath, hemoptysis or wheezing.
GASTROINTESTINAL: See HPI.
MUSCULOSKELETAL: She denies joint or muscle pain, aches or inflammation.
NEUROLOGIC: She denies headaches or focal neurologic defects.
PSYCHIATRIC: She denies change in mood, affect or behavior.
HEMATOLOGIC: She denies abnormal bruising or bleeding.
ALLERGIC/IMMUNOLOGIC: She denies unexplained or recurrent infections.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2, pulse 90, respirations 18, and blood pressure 142/76.
GENERAL: The patient is well developed, well nourished, in no acute distress.
HEENT: Pupils are equal and round. Oropharynx is clear.
HEART: Regular rate and rhythm. Systolic ejection murmur is present.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, positive bowel sounds, nontender, nondistended.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Motor and sensory grossly intact.
LABORATORY DATA: Hemoglobin 6.6 on admission. Repeat hemoglobin currently pending. INR 2.54.
IMPRESSION:
1. Anemia.
2. History of colon polyps.
PLAN: We are currently awaiting her repeat hemoglobin level from today. We will continue to give her blood transfusion until her hemoglobin level is over 8. We will also give her one dose of vitamin K 10 mg orally. We will place 2 units of fresh frozen plasma on hold. We will continue her on IV Protonix. We will plan on doing an EGD and colonoscopy tomorrow with monitored anesthesia care for further evaluation. The risks, benefits, and alternatives to the procedure were explained to the patient. She expressed understanding. Further recommendations will follow after the endoscopic procedures are completed.
