DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: DVT history.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old lady transferred from the nursing home because of left lower extremity DVT. She had repeat Doppler performed in the hospital over here, which reveals presence of proximal left superficial femoral vein thrombosis and popliteal vein thrombosis. She is currently on anticoagulation. Hematology has been consulted for treatment recommendations. It appears that the patient is quite bedridden on most occasions, and the DVT is likely to be secondary to venous stasis and immobility. The patient has a past history of GI bleed and has been scoped three months ago with symptoms of hematemesis. EGD revealed evidence of esophagitis and small area of hemorrhagic gastritis, which had no active bleeding at that point. On today’s admission, the patient does not have any GI bleeding. She has a history of chronic renal failure and hypertension as well.
PAST MEDICAL HISTORY: As mentioned above.
PAST SURGICAL HISTORY: Significant for PEG tube placement and history of filter placement, which is questionable.
MEDICATIONS: At this point include Protonix, Novolin, zinc sulfate, ascorbic acid, and Procrit.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient currently lives at a nursing home. She does not appear to have history of tobacco smoking.
REVIEW OF SYSTEMS: As per history of present illness, otherwise unobtainable and negative.
PHYSICAL EXAMINATION:
GENERAL: She is comfortable, in no distress.
VITAL SIGNS: Stable.
HEENT: No pallor. No icterus noted. Mucous membranes are moist.
NECK: Supple. No lymphadenopathy.
LUNGS: Clear to auscultation.
HEART: S1 and S2 present. There is no S3, no S4, no murmurs.
ABDOMEN: Soft. No hepatosplenomegaly.
EXTREMITIES: Left lower extremity, there is some chronic skin changes present with some swelling and warmth as well.
IMPRESSION AND PLAN:
1. The patient is an elderly lady with deep vein thrombosis of her left lower extremity. Her risk factors include chronic immobility. At this point, we would recommend anticoagulation. We would hold filter placement until and unless active gastrointestinal bleeding is present. This is because the patient is symptomatic at this point. There is a questionable history of filter placement. We would like to check chest x-ray to check for filter placement. If there is no filter placement from before, we would like to consider it if ongoing GI bleeding is present and anticoagulation becomes difficult.
2. Anemia, normocytic-normochromic. We will check iron studies, could be secondary to chronic disease.
Thank you, Dr. John Doe, for allowing us to participate in the care of this patient.
