DATE OF SERVICE: MM/DD/YYYY
DIAGNOSIS: Lung cancer, clinical stage T4N0M0, stage IIIB. The patient presented with a mass involving the right lower lobe. This was a clinical diagnosis as a biopsy was felt to be too risky for this patient given her severe chronic obstructive pulmonary disease.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with oxygen-dependent COPD who presented with a large right lower lobe mass three years ago. PET/CT at that time revealed a right lower lobe mass with an SUV of 19 with loss of a flat plane between the mass and the bronchial system and the left atrium. The mass was surrounding the right lower lobe bronchus. She had hemoptysis.
The patient underwent a split course of palliative radiation therapy receiving 3000 cGy over 10 fractions followed by a two-week break and an additional 2100 cGy over 7 fractions. All treatments completed two years ago. She is now approaching three years out from completing this palliative course of radiation therapy treatments. She continues to do surprisingly well. She has no hemoptysis. She has baseline dyspnea with exertion. She tries to wear her oxygen as best as she can, but she does not really wear it 24/7. Appetite is stable. Energy level is stable.
REVIEW OF SYSTEMS: Ten-point review of systems was performed. She notes fatigue, which she scores as a 5 on a scale of 0 to 10. Occasional headaches, occasional earaches. She has hearing loss. She notes swelling in her hands and feet and irregular heart rate. She notes wearing glasses for vision correction, eye disease and blurred vision. Chronic shortness of breath and wheezing. Frequent urination and urinary incontinence. Some abdominal discomfort, occasional nausea and loss of appetite. Joint stiffness and pain, weakness with walking.
CURRENT MEDICATIONS: Albuterol nebulizer; Neurontin 200 mg morning, 200 mg midday, and 400 mg evening; metoprolol 50 mg one p.o. daily; Lasix 20 mg one p.o. daily; potassium 10 mEq one p.o. daily; Cozaar 100 mg one p.o. daily; prednisone 5 mg one p.o. daily; diltiazem 300 mg one p.o. daily; Coumadin 4 mg one p.o. daily; Lortab 7.5 mg as needed for pain; and Nitrostat 0.4 mg as needed for chest pain.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2, pulse 80, blood pressure 128/72, pulse oximetry 90% on room air. Weight 140 pounds.
GENERAL: The patient looks fairly well.
HEENT: Normocephalic and atraumatic. EOMI. PERRLA. Sclerae are without icterus. Intraorally, her mucosa is smooth and pink without ulceration or exudate.
LYMPH NODE SURVEY: We detect no cervical, supraclavicular, axillary adenopathy on either side.
SKIN: No abnormal nevi, ecchymosis, petechiae, or rashes.
LUNGS: Lung sounds are decreased throughout, but clear. No wheezes or rales noted.
CARDIAC: Reveals an irregular rhythm. No murmur noted.
EXTREMITIES: Without cyanosis, clubbing, edema or deep calf tenderness.
PSYCHIATRIC: Normal mood and affect, appropriate to situation. Normal judgment.
IMAGING STUDIES: The patient had a CT scan earlier this morning. We were able to review the report as well as the images. She has stable cardiac enlargement. She does have enlargement of the right atrium. She has some soft tissue surrounding the bronchovascular structures in the right lower lobe without mass identified. Minimal infiltrate or atelectasis in the right lower lobe. All findings are stable compared to a CT scan obtained six months ago.
IMPRESSION AND PLAN: We have reviewed the results of the CT scan with the patient and her daughter. We have told them that all imaging studies are stable. She does not appear to have any progression or recurrence of her lung cancer. She has done amazingly well three years out from palliative course of radiation therapy treatments. We will see her back again in six months with a followup diagnostic chest CT with contrast.
