DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Neutropenia and anemia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with past medical history significant for systemic lupus erythematosus diagnosed about two years ago. The patient was on prednisone 10 mg a day, which was recently stopped prior to the patient getting admitted to the hospital. The patient was admitted with complaints of abdominal pain, which apparently started about three months ago. The patient has had multiple evaluations in the past, but no apparent etiology for abdominal pain has been established at this point in time. Upon admission, the patient was found to have elevated liver function tests. The patient was also found to have fevers over the last three to four weeks. After admission, the patient was found to be anemic and neutropenic and as such hematology consultation was requested. The patient has been aware of anemia but denies any awareness of neutropenia. The patient has been menstruating but her menstruation has not been heavy in the past. She does complain of nausea but denies having any vomiting or diarrhea. Pain in the abdomen is in the left upper quadrant. The patient’s white blood cell count on admission was 3100 with 66% neutrophils, hemoglobin was 10.4, and platelet count was 192,000.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: As above.
ALLERGIES: No known allergies.
PHYSICAL EXAMINATION: The patient appears to be in no acute distress. Vital signs are stable. T-max is 101.2 degrees. HEENT: The patient has facial rash. Neck: Supple. No JVD. Chest: Clear to auscultation. Heart: S1, S2. Abdomen: Soft. Mild tenderness in the left upper quadrant. Bowel sounds are present. Neurologic: No gross neurologic deficits.
LABORATORY DATA: WBC count 3.1, hemoglobin 9.2, hematocrit 27.4, MCV 84, platelet count 162,000. PTT 33, INR 1.04. Sodium 133, potassium 3.9, chloride 106, carbon dioxide 24, glucose 96, BUN 9, creatinine 0.9, calcium 7.6, albumin 2.4, total protein 6.9, globulin 4.4, total bilirubin 0.6, alkaline phosphatase 238, ALT 138, AST 378, amylase 68, lipase 278.
IMPRESSION:
1. Neutropenia, likely due to autoimmunity secondary to systemic lupus erythematosus.
2. Normocytic-normochromic anemia, likely as a consequence of anemia of chronic disease from systemic lupus erythematosus as well, but other possible etiologies have to be ruled out.
RECOMMENDATIONS: Would obtain serum immunofixation, LDH, vitamin B12 and folate levels. An iron panel would be done as well. Coombs test, both direct and indirect, would be done as well along with the reticulocyte count. The patient would need to be evaluated for systemic lupus erythematosus. Should the patient’s hematocrit drop below 25, then we can consider transfusing packed RBCs. The patient’s white blood cell count is adequate at the present time, and there is no need for any cytokine support. We would continue to follow this patient with you.
Thank you, Dr. John Doe, for involving us in the care of this patient.
