DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation for removal of Port-A-Cath.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old Hispanic male with known history of lung cancer. The patient was treated with external beam radiation therapy as well as systemic chemotherapy. The patient has history of deep venous thrombosis involving the lower extremities. This has been treated with both inferior vena cava filter as well as Coumadin therapy. The patient was admitted to the emergency department complaining of neck swelling and upper extremity swelling. The patient had workup done involving Doppler study that reveals deep venous thrombosis involving the upper extremity veins as described above. The patient does have an indwelling Port-A-Cath in the subclavian vein placed by us previously.
PAST MEDICAL HISTORY: Outlined above. Also, the patient has history of hypertension and dyslipidemia.
MEDICATIONS: Please see the chart for full details.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient admits to ongoing cigarette and tobacco use. He denies any alcohol intake.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION:
GENERAL: The patient appears his stated age and is in no distress.
HEENT: Normocephalic. No sclerae icterus noted. Benign oropharynx.
NECK: No jugular venous distention. No carotid bruits. Trachea is midline. No thyroid enlargement.
LUNGS: Clear to auscultation.
HEART: Normal S1 and S2 without any murmur.
ABDOMEN: Soft and nontender. No mass and no organomegaly.
EXTREMITIES: No swelling in the upper extremities. Palpable femoral pulses are noted. No edema in the lower extremities. Good range of motion.
NEUROLOGIC: The patient is nonfocal.
FINDINGS AND RECOMMENDATIONS:
1. Deep venous thrombosis involving bilateral upper extremities, involving the jugular and subclavian vein on the left side, involving jugular, subclavian vein, and axillary brachial, radial, and ulnar veins on the right.
2. Chronic Coumadin therapy.
3. Indwelling inferior vena cava filter.
4. Non-small cell lung carcinoma of the lung treated with systemic chemotherapy and external beam radiation therapy.
After carefully reviewing the patient’s chart, x-rays, laboratory data as well as examining the patient, the patient requires removal of the Port-A-Cath. We will be giving the patient fresh frozen plasma in order to bring his INR level down; currently, it is 3.96, on admission. In the meantime, the procedure was fully explained to the patient. All risks, benefits, and options were discussed, and the patient wished to proceed with the surgery.
Thank you for allowing us to participate in the care of this patient.
