EXAMPLE
Ronald Yanagihara, M.D.
CONSULTATION
_________________________________
REASON FOR CONSULTATION: I am kindly asked by Dr. George Green to
evaluate this older man with chronic anemia, now admitted for
altered level of consciousness.
HISTORY OF PRESENT ILLNESS: The patient is a 92-year-old who has
recently established care with Dr. George Green for chronic
anemia. Computer database documents a total 14 unit RBC
transfusions given over the past 24 months. Earliest CBC in
database dates to 11/03 on which WBC was 9.1, HB 10.5, HCT 31,
MCV 91, PLT 65, BUN 14, creatinine 1.0, albumin 3.3, globulins
3.8. Two days later (11/21/03) HB was 8.3 and he was given 1 unit
RBC.
One year later (11/27/04) WBC was 5.0 with 64% granulocytes, 26
lymphs, 8 monos, 2 basos, RBC 2.6, HB 7.7, HCT 23, MCV 92, PLT
81, BUN 24, creatinine 1.7. He was transfused 3 units RBC.
Subsequent RBC transfusions have been 2 units on 1/13/05 (HB
10/HCT 30), 4 units RBC on 6/16/05 (HB 7.1/HCT 22). Most recently
he was in hospital 10/13/05 complaining of lightheadedness. WBC
was 4.6 with 62% granulocytes, 24 lymphs, 11 monos, RBC 1.8, HB
5.5, HCT 17, MCV 95, PLT 47. Retic count was 0.5% and ESR 32 mm
per hour. BUN was 44, creatinine 3.7, albumin 3.3, globulin 3.1,
serum iron 103, and transferrin saturation 32%. PSA was 4.3
ng/mL. Electrophoresis showed polyclonal increase in IgA. He was
given 4 units RBC to a discharge level of HB 9.5/HCT 30 on
10/16/05. When evaluated in office on 10/25/05, he appeared well.
There was no lymphadenopathy or organomegaly. On that date WBC
was 11.5 with 80% granulocytes, 15% lymphs, 5% monos, RBC 3.66,
HB 10.9, HCT 33.6, MCV 92, PLT 198. He had bone marrow aspirate
and biopsy, which was read at Stanford as hypercellular marrow
with left-shifted myelopoiesis, myeloid hyperplasia with
dysplastic neutrophils and mild erythroid dyspoetic changes and
dysplastic megakaryocytes. There was no increase in blasts. Iron
stores were increased without ring sideroblasts. Overall the
pattern was concerning for myelodysplastic syndrome. Patient was
begun on that date on empiric EPO and received 40,000 units
weekly (x3, last dose 11/07/05). He has now been admitted or he
has now been admitted via ED on 11/10/05 because of acute episode
of altered level of consciousness. At ED evaluate WBC was 6.0,
RBC 3.6, HB 10.4, HCT 34, MCV 92, PLT 86, BUN 35, creatinine 3.5.
Spouse states that overnight he apparently became lucid again but
that today he is again confused. In ED head CT showed age-related
atrophy. RLE Doppler showed no DVT.
PAST MEDICAL HISTORY: Remarkable for recurrent anemia as
described as well as chronic renal failure as noted (plasma
creatinine was, plasma creatinine has been greater than 3.5 ng/dL
since at least mid 6/05)
PAST SURGERIES: Have included a tonsillectomy, hernia RFE,
rotator cuff repair, and TURP (1988, no cancer).
ALLERGIES: He denies allergies.
MEDICATIONS: Only chronic medication is Norvasc. He has also
recently been on EPO.
SOCIAL HISTORY: He is married and lives with his wife in Morgan
Hill. He quit cigarette smoking 30 years ago and does have one
drink nightly.
PHYSICAL EXAMINATION: BP 120/58, P 66, R 24, T 99. He appears
comfortable at rest. HEENT: Anicteric pupils 3 mm equal
reactive, extraocular movements full. THROAT: Clear. Tongue
midline. NECK: Supple without goiter lymph nodes are not palpable
at neck or supraclavicular spaces. LUNGS: Are clear to percussion
and auscultation. HEART: Regular without gallop. ABDOMEN:
Scaphoid and soft, and without palpable liver spleen or masses.
On extremity exam there is mild right leg edema. NEUROLOGICALLY:
He moves all extremities and there is no lateralizing weakness in
arms or legs. He is oriented to place and initially gives as year
“1905”, with quick correction. He is unable to do the first step
of serial 7 subtractions.
ASSESSMENT:
1.
Acute delirium in older man; consider occult infection.
2.
Recurrent grade 3-4 anemia associated with grade 1-3
thrombocytopenias since 11/04 in 94-year-old man.
a.
14-unit RBC transfusion requirement since 11/03, (most
recently 1/13/05, 6/16/05, 10/13/05).
b.
Exacerbated by chronic renal failure with progressive
azotemia since 6/05.
c.
Bone marrow consistent with myelodysplastic syndrome
(10/25/05).
d.
No response to weekly EPO (10/25/05, weekly x 3).
PLAN: Patient will have chemistry panel done to assess calcium
status. He will have blood cultures and urinalysis and will be
started empirically on Ceftriaxone. A fourth dose of EPO will be
ordered, a fourth dose of EPO 40,000 units will be ordered for
11/14/05. Assuming continued lack of response, however,
consideration will then be given to other therapy.