DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Prostate cancer.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic gentleman. He was admitted for chest pain and recurrent CHF. He has been followed for elevated PSA. Unfortunately, he does not know the details of prior PSA levels, but the records include a PSA of 10.6 from six months ago. Last month, he had a prostate biopsy, and the pathology report describes few atypical glands, probable carcinoma on the left and Gleason 4+3 cancer on the right. Percentage of cancer is not described, and the prostate ultrasound report is not included. He has not had any staging or treatment to date. He has frequent urination secondary to diuretic use, but otherwise denies any voiding problems. No history of dysuria, hematuria, stones or infections.
PAST MEDICAL HISTORY: Coronary artery disease, congestive heart failure with ejection fraction 20%, chronic renal insufficiency with a baseline creatinine 1.6 to 2, hypertension, and diabetes.
PAST SURGICAL HISTORY: No surgeries.
MEDICATIONS: Plavix, aspirin, Lovenox, insulin, Lanoxin, enalapril, Lipitor, Coreg, and Protonix.
ALLERGIES: None.
SOCIAL HISTORY: The patient quit smoking 25 years ago.
FAMILY HISTORY: Hypertension and diabetes.
REVIEW OF SYSTEMS: No significant bone or joint pain.
PHYSICAL EXAMINATION:
GENERAL: A pleasant Hispanic male, alert and oriented.
VITAL SIGNS: Normal vital signs.
ABDOMEN: Obese.
EXTREMITIES: Bilateral lower extremity edema.
RECTAL: On digital rectal exam, prostate size difficult to estimate due to a flat contour, likely mild enlargement with mild nodular induration towards the right mid gland and apex.
LABORATORY DATA: White count has declined from 13,500 to 11,000, hemoglobin stable at 10.8, and normal platelet count. PSA 8.4, creatinine 1.8 to 1.9, normal alkaline phosphatase, and AST and ALT both in the 20s.
ASSESSMENT AND PLAN: Recently diagnosed prostate cancer. On the basis of his current PSA level and pathology findings, still a reasonable likelihood that the disease is organ confined and would respond to local therapy. He obviously has considerable medical comorbidity. We will request a bone scan and CT scan of the abdomen and pelvis while he is here in the hospital to look for obvious metastatic disease. We would expect that he will be ready for discharge home within the next few days and then we can see him back in the office to discuss the test results and management options.
