DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Myelodysplastic syndrome and pancytopenia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old man diagnosed with myelodysplastic syndrome several months ago when he presented with progressive pancytopenia. We have followed him in the office, and unfortunately, despite supportive care with Procrit and intermittent transfusions, his pancytopenia has worsened over time. He has had several hospitalizations for congestive heart failure due to ischemic cardiomyopathy. He is now admitted for right upper extremity cellulitis versus gout versus pseudogout. Since admission, he has undergone treatment with antibiotics and has received transfusion of packed RBCs. The patient continues on weekly Procrit.
PAST MEDICAL HISTORY: As above, atrial fibrillation, chronic renal insufficiency, hyperlipidemia, coronary artery disease, hypertension, ischemic cardiomyopathy, and lumbar stenosis.
SOCIAL HISTORY: The patient is divorced. Smoking: None currently. Alcohol: None.
FAMILY HISTORY: No malignancy.
REVIEW OF SYSTEMS: Positive for chronic shortness of breath, profound weakness, anorexia, fatigue and an itching rash, which is gradually resolving.
PHYSICAL EXAMINATION:
GENERAL: The patient is a frail man, in no acute distress.
VITAL SIGNS: Temperature 97.4, pulse 94 and regular, respirations 16, and blood pressure 120/52.
HEENT: Normocephalic and atraumatic. Oral mucosa is moist.
NECK: Lymph nodes. No palpable supraclavicular, infraclavicular, cervical, axillary, inguinal adenopathy.
HEART: Irregularly irregular.
LUNGS: There are crackles at the bases bilaterally.
ABDOMEN: Bowel sounds are present. The abdomen is soft and nontender without organomegaly.
GENITALIA: Normal external male genitalia.
NEUROLOGIC: No focal deficit.
HEMATOLOGIC: Scattered ecchymosis.
SKIN: Resolving rash on the back, peeling skin on the right hand at the site of previous swelling. Significant for pallor. There is no jaundice.
LABORATORY DATA: BUN 56 and creatinine 1.5. White blood cell count 28,000, hemoglobin 7.2, hematocrit 24.4, and platelets 32,000.
ASSESSMENT:
1. Myelodysplastic syndrome with worsening pancytopenia. The patient has declined low intensity chemotherapy. We are continuing supportive care with Procrit and transfusions to attempt to keep hemoglobin greater than 7.5.
2. Ischemic cardiomyopathy.
3. Rash, resolving.
4. Right hand cellulitis, improving.
5. Chronic renal insufficiency.
6. Coronary artery disease.
RECOMMENDATIONS: Continue weekly Procrit and transfuse to keep hemoglobin greater than 7.5. Follow up with us next week. Unfortunately, this gentleman’s prognosis is poor. He would be an inappropriate patient for hospice care. His daughter has durable power of attorney for health care. The patient seems to understand the seriousness of his multiple medical problems at this time.
