DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman who was scheduled yesterday to have a left knee replacement for chronic pain. She has been on Coumadin since many years, after a myocardial infarction and possible antiphospholipid antibody syndrome and was switched over to Lovenox, I believe, this past Tuesday in preparation for her knee replacement surgery. One day later, this past Wednesday, she developed gross hematuria which persisted on Thursday, and as of yesterday, she was still passing “clots.” The patient has had some suprapubic pain recently as well. The patient has never had hematuria in the past.
PAST MEDICAL HISTORY: The patient was diagnosed, I believe, in the remote past with SLE or lupus. Apparently has a false positive RPR that goes back many years. Long history of various types of chronic pain in her arms, legs, hands. No rash, no photosensitivity, some thinning of hair, mild dry eyes and mouth but no problem with moistening of her food, and she does produce tears. No history of seizure disorder, dysphagia, dyspepsia, weakness, serositis or Raynaud phenomenon. She is para 4, gravida 2, two miscarriages at 3 months. No history of any strokes or any deep venous thrombosis. She had a myocardial infarction in the past, treated with a stent. Hypertension since many years. History of panic attacks since her divorce 4 years ago. History of depression. The patient states that she had an abnormal urinalysis, possibly urinary tract infection, I believe, in the recent past and has had recurrent urinary tract infections over the years.
PAST SURGICAL HISTORY: Hysterectomy and oophorectomy in the remote past; right knee arthroscopic surgery last year; bilateral carpal tunnel surgery 5 years ago; three D and Cs; lymph node resection in the remote past, no apparent diagnosis; tonsillectomy.
OUTPATIENT MEDICATIONS: Coumadin since many years, as noted above, prednisone 5 mg every morning for the past 7 years, Plaquenil 200 mg one daily for the past 7 years. Flexeril as needed for leg cramps, Ambien 10 mg at bedtime as needed for sleep, Toprol 25 mg per day, Lexapro, Lipitor 10 mg per day, Xanax, Vicodin up to about 3 a day, Dilaudid for knee pain.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
FAMILY HISTORY: Father deceased at 89. Mother deceased from lupus at age 67. She says that her maternal grandmother had lupus. She has two children. Daughter has fibromyalgia. The son is alive and well. She has one sister with coronary artery disease. Another sister may have lupus recently diagnosed.
SOCIAL HISTORY: The patient is divorced.
REVIEW OF SYSTEMS: Chronic pain in the knees, chronic myalgias and arthralgias.
PHYSICAL EXAMINATION:
GENERAL: The patient is an afebrile, pleasant woman, in no acute distress.
VITAL SIGNS: Stable.
HEENT: Head normocephalic. Eyes without evidence of hemorrhages, icterus or pallor. Mouth within normal limits.
NECK: Without masses, adenopathy or thyromegaly.
HEART: Regular rate and rhythm without murmurs, rubs or gallops.
LUNGS: Clear to auscultation.
ABDOMEN: Soft without apparent masses, tenderness or organomegaly.
EXTREMITIES: Without edema, cyanosis or clubbing. Good dorsalis pedis pulses bilaterally. Articular exam is entirely normal in the upper and lower extremities. Both knees have good range of motion. Hips normal. Gait was normal, tested at the bedside.
NEUROLOGIC: Deep tendon reflexes +2/4 at the biceps, triceps, patella and Achilles. Excellent proximal and distal muscle strength in the upper and lower extremities.
SKIN: Few ecchymotic areas in the subcutaneous tissue of the abdomen.
LABORATORY DATA: The patient’s most recent CMP was reviewed. Carbon dioxide was elevated at 34, calcium was mildly low at 8.3, otherwise normal. Prothrombin time and INR were normal. PTT was minimally elevated at 34.2. Her most recent CBC was normal. Hemoglobin was 12.4 and RBC minimally reduced to 4. Most recent urinalysis showed 10-15 white cells per high power field, otherwise essentially normal. No blood reported.
ASSESSMENT:
1. History of systemic lupus erythematosus diagnosed a number of years ago with a history of myalgias, arthralgias, other chronic diffuse pain, false positive RPR, positive ANA by history. This was all given by the patient. Certainly, I cannot confirm the diagnosis based on this initial consultation, but she has been followed in our practice for SLE, apparently for several years now.
2. Bilateral knee pain. Was scheduled for total knee placement on the left side.
3. Gross hematuria while on Lovenox.
4. History of urinary tract infections.
5. Chronic narcotic use with the use of Vicodin and Dilaudid for her various aches and pain, in particular I believe, for her knee pain.
6. History of possible antiphospholipid antibody syndrome with a history of myocardial infarction in the past.
RECOMMENDATIONS: We will check urine culture and sensitivity, ANA, rheumatoid factor, anticardiolipin antibody, lupus anticoagulant. Urologic workup is pending with the urologist. I have also ordered x-rays of her knees. We will continue the patient’s prednisone at 5 mg q.a.m. with food and her Plaquenil 200 mg one daily and we will check her CPK level.
Thank you for allowing me to see your patient in consultation.
