Universal Dependencies - English - GENTLE

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Description:

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Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension.

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The patient is here for followup visit and chemotherapy.

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CHIEF COMPLAINT:

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The patient is here for followup visit and chemotherapy.

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DIAGNOSES:

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1. Posttransplant lymphoproliferative disorder.

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2. Chronic renal insufficiency.

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3. Squamous cell carcinoma of the skin.

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4. Anemia secondary to chronic renal insufficiency and chemotherapy.

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5. Hypertension.

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HISTORY OF PRESENT ILLNESS:

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A 51-year-old white male diagnosed with PTLD in latter half of 2007.

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He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia.

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He did not seek medical attention immediately.

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He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma.

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He was discussed at the hematopathology conference.

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Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started.

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First cycle of chemotherapy was complicated by sepsis despite growth factor support.

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He also appeared to have become disoriented either secondary to sepsis or steroid therapy.

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The patient has received 5 cycles of chemotherapy to date.

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He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well.

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His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.

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The patient is here for the sixth and final cycle of chemotherapy.

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He states he feels well.

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He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue.

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He denies any tingling or numbness in his fingers.

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Review of systems is otherwise entirely negative.

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Performance status on the ECOG scale is 1

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PHYSICAL EXAMINATION:

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VITAL SIGNS:

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He is afebrile.

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Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit.

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There is mild pallor noted.

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There is no icterus, adenopathy or petechiae noted.

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CHEST: Clear to auscultation.

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CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm.

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Systolic flow murmur is best heard in the pulmonary area.

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ABDOMEN: Soft and nontender with no organomegaly.

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Renal transplant is noted in the right lower quadrant with a scar present.

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EXTREMITIES: Reveal no edema.

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LABORATORY DATA:

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CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.

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ASSESSMENT AND PLAN:

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1. Diffuse large B-cell lymphoma following transplantation.

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The patient is to receive his sixth and final cycle of chemotherapy today.

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PET scan has been ordered to be done within 2 weeks.

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He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.

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2. Chronic renal insufficiency.

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3. Anemia secondary to chronic renal failure and chemotherapy.

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He is to continue on his regimen of growth factor support.

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4. Hypertension.

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This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled.

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His CMP is pending from today.

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5. Squamous cell carcinoma of the skin.

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The scalp is well healed.

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He still has an open wound on the right posterior aspect of his trunk.

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This has no active drainage, but it is yet to heal.

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This probably will heal by secondary intention once chemotherapy is finished.

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Prescription for prednisone as part of his chemotherapy has been given to him.