DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Lung mass, rule out TB.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic man with a past medical history significant for diabetes mellitus, hypertriglyceridemia, and seizure disorders. The patient also has a history of smoking but repots that he stopped smoking for the past two years. The patient developed a cough productive of yellowish sputum and was treated empirically with Levaquin for 10 days without improvement in his symptoms. The patient was further evaluated with a chest x-ray, which revealed right upper lobe density. CAT scan was obtained and demonstrated a large right upper lobe mass with central necrosis. The patient was referred to this hospital and was placed on respiratory isolation. PPD was placed to rule out tuberculosis. He was started on IV Rocephin and Zithromax, and a CT-guided biopsy was obtained. Infectious disease consult was called to evaluate the patient and assist with treatment.
PAST MEDICAL HISTORY: As mentioned above.
MEDICATIONS: The patient is currently on ceftriaxone 2 grams once a day, Zithromax 500 mg once a day, and regular insulin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married. He denies ETOH use and no drug use.
REVIEW OF SYSTEMS: Positive for cough and mild shortness of breath. Denies weight loss. No night sweats. No sick contacts. No chills. No headaches. No visual changes. No abdominal pain. No diarrhea. No urinary frequency or urgency.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: No acute distress. Lying in bed and appears comfortable.
VITAL SIGNS: Temperature 100.2, BP 128/64, heart rate 118.
HEENT: Pupils are reactive. Conjunctivae are moist. No icterus. No conjunctival hemorrhage.
NECK: Supple. No JVD or lymph nodes palpable.
LUNGS: Clear to auscultation. No rhonchi or wheezes.
HEART: S1 and S2, regular. No rub, gallop or murmur.
ABDOMEN: Soft. No tenderness on palpitation. Bowel sounds present. No hepatosplenomegaly.
EXTREMITIES: There is 2+ ankle edema, more so present on the right pretibial region. No clubbing or cyanosis. Pulses are 2+.
NEUROLOGIC: The patient is awake, alert, and oriented x3. No focal deficits.
LABORATORY DATA: WBC count 10.4, hemoglobin 11.6, platelets 502. AST 76, ALT 234, and total bilirubin 0.4. Cultures and pathology reports are still pending.
ASSESSMENT AND PLAN: This is a (XX)-old-man with a history of diabetes mellitus. The patient was admitted with cough and CT scan which revealed right upper lobe mass with cavitation. The patient has a history of smoking and quit two years ago. He denies any sick contacts that would put him at high risk for tuberculosis. He also denies any travel outside of this area and no exposure to any patients with tuberculosis.
PLAN:
1. Would follow the results of his CT-guided biopsy.
2. We will continue the patient on respiratory isolation.
3. Would change the antibiotics from Rocephin and Zithromax to IV Unasyn to cover possibility of lung abscess.
4. Would also obtain ultrasound of both legs due to edema that was noted on the physical exam to rule out deep venous thrombosis as well.
5. Will follow the patient with you and assist with treatment.
