DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Metastatic prostate carcinoma.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old patient with metastatic prostate cancer, back pain, nausea, vomiting, and compression fractures related to his bone metastasis.
PAST MEDICAL HISTORY: Prostate CA, bone metastasis, and radiation treatment. Hypertension, diabetes, esophageal tear. The patient is receiving chemotherapy as an outpatient and radiation therapy. He is receiving radiation therapy while he is here.
PAST SURGICAL HISTORY: Coronary artery bypass graft x5, hernia repair, appendectomy, exploratory laparotomy, cataract implant, cholecystectomy, and prostatectomy.
MEDICATIONS: Flutamide, metoprolol, triamterene, Lipitor, enalapril, Zetia, Plavix, dexamethasone, oxycodone, Lunesta, and Lyrica.
REVIEW OF SYSTEMS: No complaints of nausea, vomiting, fever or chills. No bleeding from his gums, epistaxis or bleeding from his rectum. No petechia or bruising. No shortness of breath or chest pain. His only complaint is back pain at times.
PHYSICAL EXAMINATION:
GENERAL: The patient is awake, alert, and oriented x3.
NECK: Supple. Trachea is midline. No lymphadenopathy.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales.
HEART: S1 and S2.
ABDOMEN: Soft and nontender. No hepatosplenomegaly. Bowel sounds are positive in all four quadrants. No rebound, tenderness or guarding.
EXTREMITIES: Warm and dry. Palpable pulses. No clubbing, cyanosis or edema.
IMPRESSION: Metastatic prostate cancer with bone metastasis. He is receiving chemotherapy as an outpatient, and he is receiving radiation therapy currently while he is here. He came in with nausea and vomiting, which has resolved, and he has compression fractures due to his bone metastasis.
PLAN:
1. Monitor labs.
2. Supportive care.
3. Dr. Jane Doe is following this patient. She will follow up daily and monitor his labs and support while he is here and then continue to follow up once he is discharged for chemotherapy.
