DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Sickle cell disease.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male admitted for evaluation of chest pain and dizziness. The patient was recently hospitalized less than one week ago for evaluation and treatment of dizziness and vertigo. He now presents with chest pain, specifically left and right chest pain, in the area of the costophrenic angles. The patient states he has had this pain for approximately the last five days with no improvement. He is also complaining of persistent dizziness as well. He recently had a CT of the chest. It did show some bilateral pleural thickening and either scarring or atelectatic changes in the right middle lobe, lower lobe, and lingula. The patient also has a fever of 102 degrees and has been started on antibiotics empirically with Zosyn. He is also currently undergoing ultrasound of the chest to rule out pericardial effusion.
PAST MEDICAL HISTORY: Significant for sickle cell disease.
PAST SURGICAL HISTORY: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is divorced. He reports no cigarette use. No ETOH.
ALLERGIES: No known allergies.
CURRENT MEDICATIONS: Includes folic acid 1 mg p.o. daily as well as oxycodone p.r.n. pain.
REVIEW OF SYSTEMS: The patient reports no recent weight loss. He has been febrile within the last 24 hours. He reports no loss of appetite. He complains of bilateral chest pain, worse with movement and deep inspiration. He complains of shortness of breath with exertion, and dizziness. No headaches. No palpitations. No abdominal pain. No nausea, vomiting or diarrhea. No dysuria or hematuria. No focal weakness. No new skin rashes or lesions.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented x3, in no acute distress.
VITAL SIGNS: Blood pressure 128/54, pulse 102, respiratory rate 18, and temperature 102.4 degrees.
HEENT: Unremarkable.
NECK: Supple. No lymphadenopathy.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation throughout.
ABDOMEN: Soft and nontender. Bowel sounds are present.
EXTREMITIES: Symmetrical. Normal strength bilaterally. Pulses are palpable. No edema, clubbing or cyanosis.
LABORATORY DATA: CBC today shows white count 13.8, hemoglobin 7.6, hematocrit 21.2, and platelets 262,000. MCV 80, ANC 7.2, creatinine 0.5, bilirubin 2.6, AST 66, and D-dimer 1.24.
IMPRESSION:
1. Sickle cell disease.
2. Chest pain, possibly secondary to pain crisis, pneumonia, or cardiac origin. CT of the chest was significant for bilateral pleural thickening.
3. Leukocytosis. The patient was started on IV Zosyn empirically for treatment of pneumonia.
4. Microcytic anemia.
RECOMMENDATIONS: At this time, we would recommend transfusing with 2 units of PRBCs, as the patient appears to be symptomatic secondary to his anemia with complaints of chest pain, dizziness, and shortness of breath but agree with 2-D echocardiogram for further evaluation of chest pain. Also, agree with empiric antibiotic treatment at this time.
