DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Elevated total protein level and suspicion for plasma cell dyscrasia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with a past medical history significant for hypertension, who was admitted to the hospital due to failure of outpatient antibiotic therapy since the patient had pneumonia. Upon admission, the patient was found to have an elevated total protein level at 8.6 with an elevated globulin fraction, and as such, suspicion for plasma cell dyscrasia was raised, and Hematology consultation was called. Upon interviewing the patient further, he denies having any other problems, except for some mild shortness of breath and coughing.
PAST MEDICAL HISTORY: As above and significant for hypertension and pneumonia, on outpatient antibiotic therapy in the form of Avelox.
ALLERGIES: None.
SOCIAL HISTORY: The patient denies smoking or abusing alcohol.
FAMILY HISTORY: Significant for breast cancer in mother and lung cancer in father, but father was a smoker.
PHYSICAL EXAMINATION:
GENERAL: The patient is sitting in bed, appears to be in no acute distress.
VITAL SIGNS: Stable. Afebrile.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reacting to light.
NECK: Supple. No JVD.
CHEST: Clear to auscultation.
HEART: S1 and S2.
ABDOMEN: Soft and nontender.
CNS: No neurological deficits.
LABORATORY DATA: WBC count 18,200, hemoglobin 12.4, hematocrit 36.4, and platelet count 366,000. Sodium 134, potassium 4.6, chloride 106, carbon dioxide 26, glucose 236, BUN 24, creatinine 1.44, calcium 8.9, total protein 7.8, albumin 2.8, globulin 5, total bilirubin 0.2, alkaline phosphatase 128, ALT 214, AST 60, amylase 72, lipase 300.
DIAGNOSTIC DATA: The patient underwent a V/Q scan, which was normal. Ultrasound of the gallbladder demonstrates a fatty infiltration of the liver and a right pleural effusion. Chest x-ray done demonstrates mild interval improvement in the right lower lobe consolidation. No pneumothorax was identified. The patient underwent serum protein electrophoresis, which did not demonstrate a monoclonal protein.
IMPRESSION: Elevated total proteins in a patient with pneumonia with serum protein electrophoresis demonstrating polyclonal hypergammaglobulinemia, most likely as a consequence of infection and inflammation. The patient likely does not have a plasma cell dyscrasia.
RECOMMENDATIONS: For completeness sake, we would obtain a serum immunofixation. Case was discussed at length with the patient, and he was made aware of these recommendations. The patient can be discharged from a hematology standpoint, and we would continue to follow him on an outpatient basis should he desire.
