DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Renal cell carcinoma, metastatic to bone, now with progression of disease in the thoracic spine with spinal cord compression.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with known history of renal cell cancer, metastatic to bone. He has previously undergone palliative radiation treatment to multiple sites including the left humerus, right forearm and the upper thoracic spine, as well as mid thoracic spine. Specifically, he has received prior radiation treatment in the thoracic spine down to the level of thoracic vertebral body 8. At this time, he is admitted here for evaluation and management of shortness of breath. CT scans of the chest evaluated the possibility of a pulmonary embolus but were negative. The patient’s shortness of breath has been attributed to an exacerbation of asthma and has responded well to aggressive treatment. He has also noticed, however, progression of severe mid back pain. He describes pain in the vertebral region and paravertebral area of the midthoracic spine. An MRI scan of the spine was obtained and was reviewed with the radiologist. There is significant evidence for metastatic disease in the spine with extensive disease noted in vertebral bodies T7, T9 and T11. Disease is most significant in T7 with evidence of spinal cord compression. The patient is seen at this time for an opinion regarding further management. On further questioning, the patient notes difficulty in moving his legs, more because of back pain rather than true weakness. He notes no paraesthesias. There are no other symptoms of spinal cord compression. He is on prednisone 60 mg daily because of his asthma/COPD.
GENERAL: On physical examination, he appears chronically ill but stable, in no acute distress. Lymph node survey is unremarkable.
HEART: Regular in rate and rhythm.
ABDOMEN: Soft and nontender. There is no gross mass or hepatosplenomegaly.
EXTREMITIES: Without edema. There is tenderness to palpation over the mid back consistent with the MRI findings.
IMPRESSION: Renal cell carcinoma, widely metastatic to bone, symptomatic with mid back pain with radiographic evidence of spinal cord compression in a previously treated site.
RECOMMENDATIONS: I plan to initiate radiation treatment to the spine in hopes of optimizing pain management and prevention/delay of neurologic compromise. I recommend a dose of approximately 3000 centigray in 10 treatments to an area including T7 through T12. Vertebral body T7 has previously been included in radiation treatment to the upper spine, and additional radiation treatment to this site will be limited. Unfortunately, this also is currently the most extensive area of disease. One could, therefore, consider neurosurgical evaluation regarding disease at the T7 level. I have discussed the results of the imaging, as well as plans for radiation treatment with the patient. He understands the overall status of his disease. We did discuss the risks of a re-irradiation to the spine. At the time of the initial consultation, the patient was not interested in neurosurgical evaluation and we shall, therefore, initiate radiation treatment.
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