| s-1
| Description: |
| s-2
| Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension. |
| s-3
| The patient is here for followup visit and chemotherapy. |
| s-4
| CHIEF COMPLAINT: |
| s-5
| The patient is here for followup visit and chemotherapy. |
| s-6
| DIAGNOSES: |
| s-7
| 1. Posttransplant lymphoproliferative disorder. |
| s-8
| 2. Chronic renal insufficiency. |
| s-9
| 3. Squamous cell carcinoma of the skin. |
| s-10
| 4. Anemia secondary to chronic renal insufficiency and chemotherapy. |
| s-11
| 5. Hypertension. |
| s-12
| HISTORY OF PRESENT ILLNESS: |
| s-13
| A 51-year-old white male diagnosed with PTLD in latter half of 2007. |
| s-14
| He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia. |
| s-15
| He did not seek medical attention immediately. |
| s-16
| 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. |
| s-17
| He was discussed at the hematopathology conference. |
| s-18
| Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started. |
| s-19
| First cycle of chemotherapy was complicated by sepsis despite growth factor support. |
| s-20
| He also appeared to have become disoriented either secondary to sepsis or steroid therapy. |
| s-21
| The patient has received 5 cycles of chemotherapy to date. |
| s-22
| He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well. |
| s-23
| His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection. |
| s-24
| The patient is here for the sixth and final cycle of chemotherapy. |
| s-25
| He states he feels well. |
| s-26
| He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue. |
| s-27
| He denies any tingling or numbness in his fingers. |
| s-28
| Review of systems is otherwise entirely negative. |
| s-29
| 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. |
| s-33
| Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit. |
| s-34
| There is mild pallor noted. |
| s-35
| There is no icterus, adenopathy or petechiae noted. |
| s-36
| CHEST: Clear to auscultation. |
| s-37
| CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. |
| s-38
| Systolic flow murmur is best heard in the pulmonary area. |
| s-39
| ABDOMEN: Soft and nontender with no organomegaly. |
| s-40
| Renal transplant is noted in the right lower quadrant with a scar present. |
| s-41
| EXTREMITIES: Reveal no edema. |
| s-42
| LABORATORY DATA: |
| s-43
| 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. |
| s-44
| ASSESSMENT AND PLAN: |
| s-45
| 1. Diffuse large B-cell lymphoma following transplantation. |
| s-46
| The patient is to receive his sixth and final cycle of chemotherapy today. |
| s-47
| PET scan has been ordered to be done within 2 weeks. |
| s-48
| He will see me back for the visit in 3 weeks with CBC, CMP, and LDH. |
| s-49
| 2. Chronic renal insufficiency. |
| s-50
| 3. Anemia secondary to chronic renal failure and chemotherapy. |
| s-51
| He is to continue on his regimen of growth factor support. |
| s-52
| 4. Hypertension. |
| s-53
| This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled. |
| s-54
| His CMP is pending from today. |
| s-55
| 5. Squamous cell carcinoma of the skin. |
| s-56
| The scalp is well healed. |
| s-57
| He still has an open wound on the right posterior aspect of his trunk. |
| s-58
| This has no active drainage, but it is yet to heal. |
| s-59
| This probably will heal by secondary intention once chemotherapy is finished. |
| s-60
| Prescription for prednisone as part of his chemotherapy has been given to him. |