DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Left deep venous thrombosis.
2. Hypercoagulable state secondary to lupus anticoagulant.
3. Rheumatoid arthritis with left knee effusion, status post a total knee replacement.
4. Diabetes mellitus.
5. Positive ANA with negative anti-DNA.
6. Hypertension.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with history of rheumatoid arthritis and positive ANA who was sent to an outside facility for venous Dopplers because of left lower extremity pain and swelling for the past week and was found to have a DVT. The report was called to her rheumatologist, who advised her to come to this facility.
The venous Doppler study was repeated here and demonstrated DVT involving the mid superficial femoral, distal superficial femoral, and popliteal above the knee. There was also a popliteal cyst noted in the right popliteal fossa. There was no popliteal cyst noted on the left, in the leg where the DVT developed.
The patient was admitted, and hypercoagulable workup was obtained since she was ambulatory. She goes to rehab three times a week and walks on the treadmill and exercise bike for 45 minutes three times a week. However, she has been traveling recently with long car rides. She denies any history of DVT, and there is no family history of hypercoagulable state. There is no history of spontaneous abortion. She was also having pain in her knee, and there was some effusion noted on the left.
PAST MEDICAL HISTORY: Hypertension, diabetes mellitus for the past three years, rheumatoid arthritis, seizures with her last seizure 1-1/2 years ago which developed at age 18. She denies any retinopathy, nephropathy or neuropathy related to her diabetes.
PAST SURGICAL HISTORY: Remarkable for bilateral total knee replacements with repair of a torn ligament in the right ankle. She has also had surgery on her right wrist related to her rheumatoid disease.
MEDICATIONS: Prior to admission, Celebrex 200 mg daily, Enbrel, metformin 1000 mg b.i.d., Avandia 4 mg b.i.d., azathioprine 150 mg daily, Amaryl 4 mg daily, and Cozaar 100 mg daily.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.2 degrees, pulse 84, respirations 18, blood pressure 118/76, and oxygen saturation 98% on room air. HEENT: Unremarkable. No oral ulcers present. NECK: Supple. LUNGS: Clear. HEART: Regular, S1 and S2. No murmur or gallop. ABDOMEN: Soft and nontender. EXTREMITIES: Bilateral anterior knee scars from knee replacements. Left calf is warm, slightly erythematous and tender. There was no edema.
INITIAL LABORATORY DATA: PTT is 54, which is elevated. INR is 1.1. Hemoglobin 11.8, white count 7400, and platelets 198,000. Chemistries were all normal. EKG demonstrated normal sinus rhythm. No ischemic changes.
HOSPITAL COURSE: The patient was admitted and started on Lovenox. Blood work was drawn for lupus anticoagulant and anticardiolipin antibodies. Factor V Leiden was also obtained. She was started on Coumadin. Rheumatology was consulted who requested consultation with Dr. John Doe. Dr. John Doe evaluated the patient and noted a mild left effusion with no evidence of any infection and did not recommend aspiration of the knee joint. Lupus anticoagulant was positive, and anticardiolipin antibodies and factor V Leiden were both negative. The patient was dosed with Coumadin at 10 mg, 10 mg, 5 mg, 10 mg, 10 mg, and on the day of discharge, her INR was 2. She was discharged home on 7.5 mg of Coumadin with plans to follow up with her primary care physician.
ADDITIONAL LABORATORY DATA: Chemistries were all normal. C3 of 150. Urinalysis was normal with no protein. DRVVT is a confirmatory test for lupus anticoagulant and was positive at 1.6. Hemoglobin A1c was 5.8%. Ultrasound of the left popliteal region demonstrated no evidence of a Baker cyst, and x-rays of the lumbosacral spine were normal.
DISCHARGE MEDICATIONS: The patient is discharged on Coumadin 7.5 mg daily, Celebrex 200 mg daily with advice to follow up with Rheumatology for possible alternative medication because of the risk of bleeding, Enbrel, metformin 1000 mg b.i.d., Avandia 4 mg b.i.d. Amaryl 4 mg daily was held in the hospital because of lower blood sugars, and the patient was advised to hold it at home until she monitors her blood sugars at home and determines whether this medication is needed. Cozaar 100 mg daily and azathioprine 150 mg daily.
DISCHARGE INSTRUCTIONS: The patient’s INR will be followed by Dr. Jane Doe. This was discussed with her prior to her discharge. She was advised to follow up at her office in two days to have an INR drawn. She will also follow up with Rheumatology, who will advise her about resuming physical therapy and use of anti-inflammatory medications.
