DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Continued management of carcinoma of the lung.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old gentleman with a history of non-small-cell carcinoma of the lung. He has undergone radiation therapy and is now receiving chemotherapy in the outpatient setting. He presented in the office for a followup. He was extremely short of breath and was found to have an oxygen saturation of 84%. He did not respond to oxygen via nasal cannula. He was placed on an oxygen mask at 4 liters per minute. His oxygen concentration normalized at 98-100%. Unfortunately, with any speaking or any movement whatsoever, the patient continued to desaturate. He was taken immediately to the emergency department. He is now admitted for shortness of breath and is under the excellent care of the attending physician. Consultation has been placed also to Dr. Jane Doe. The patient denied headache, blurred vision or double vision. He is without nausea, vomiting or diarrhea. He does complain of generalized weakness. He has also completed oral antibiotic therapy for pulmonary infection within the past month. He has also undergone Taxol chemotherapy and at one point was on prednisone. He has been tapered from his prednisone approximately two weeks ago. He was most likely admitted with a pneumonitis; however, further treatment recommendations will be made by Dr. Jane Doe as well.
PAST MEDICAL HISTORY: Significant for carcinoma of the lung. The patient also has degenerative joint disease. He has a history of coronary artery disease. He has been recently diagnosed with type 2 diabetes mellitus.
PAST SURGICAL HISTORY: Positive for Port-A-Cath placement and coronary artery bypass graft.
MEDICATIONS: Please see the records for complete list of home medications.
ALLERGIES: None.
REVIEW OF SYSTEMS: Negative for headache, blurred vision or double vision. The patient has significant shortness of breath. He has a frequent cough. He is expectorating white mucus. He is denying fever, chills, night sweats, nausea, vomiting or diarrhea. He is denying chest pain. He complains of significant weakness. He denies neurological complaints.
PHYSICAL EXAMINATION: Reveals an alert and oriented gentleman who was quite short of breath on immediate presentation. His oxygen saturation was 84%. His saturations recovered to 100% on oxygen via mask. His lungs were diminished, but clear, without wheezing, rales or rhonchi. His heart was slightly tachycardic upon presentation; however, his heart rate returned to normal rate and rhythm once his oxygen had normalized. He is alert and oriented. His neurological examination is nonfocal. His abdomen is benign. His extremities are free of edema, clubbing or cyanosis.
ASSESSMENT AND PLAN: Non-small-cell carcinoma of the lung, status post radiation therapy, now on chemotherapy with severe shortness of breath. The patient is admitted under the excellent care of the attending physician. He is most likely suffering from an exacerbation of pneumonitis. His last chemotherapy was approximately one week ago. The chemotherapy will be placed on hold until resolution of his shortness of breath.
