DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Deep venous thrombosis/pulmonary embolism.
HISTORY OF PRESENTING ILLNESS: The patient is a (XX)-year-old female with past medical history significant for Crohn disease. The patient has a remote history of superficial phlebitis. The patient was not put on any anticoagulation at that time, and her symptoms resolved after a few days. The patient was admitted through the emergency room since she developed pain and swelling involving the left lower extremity. The patient said that she apparently had pain in her left mid thigh region, and there was apparently some swelling in the left groin region.
At presentation, she underwent Doppler studies of the left lower extremity and a clot was identified in the proximal greater saphenous vein extending into the knee area of the greater saphenous vein. The patient also underwent a CT scan of the chest and pulmonary embolus was identified and as such hematology consultation was requested. The patient gives a history of being on birth control related contraception in the recent past. The patient denies having any family history of any bleeding or clotting problems. Family history is significant for varicose veins.
PAST MEDICAL HISTORY: As above and significant for Crohn disease.
PHYSICAL EXAMINATION: The patient is lying in bed and appears to be in no acute distress. Vital signs are stable, afebrile. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reacting to light. Neck: Supple. No JVD. Chest: Clear to auscultation. Heart: S1, S2. Abdomen: Soft and nontender. Neurologic: No gross neurologic deficits. Extremities: The patient has some varicose veins involving the left lower extremity. The patient has an area of erythema and ecchymosis involving the left knee region. No obvious discernible swelling identified in the left groin.
LABORATORY DATA: Lab investigations show WBC count of 6.8, hemoglobin of 13.2, hematocrit of 39.4, and platelet count of 236,000. PTT 28, INR 1.04. Sodium 136, potassium 3.3, chloride 106, carbon dioxide 28, glucose 92, BUN 15, and creatinine 0.9. Normal liver function tests.
IMPRESSION: Deep venous thrombosis/pulmonary embolism. The patient is hypercoagulable.
PLAN: Plan would be to initiate hypercoagulable testing consisting of prothrombin gene mutation 20210A, factor V Leiden, anticardiolipin antibody IgG and IgM. Would also obtain homocysteine levels. Would do Coumadin teaching through pharmacy. The patient can follow up at the Coumadin Clinic for her anticoagulation. Anticoagulation would be recommended for a six-month duration at this point in time unless the patient has any positive hypercoagulable tendencies. The case was discussed at length with the patient, and she was made aware of these recommendations.
