DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation of systemic lupus.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Asian female well known to our clinic. The patient has history of systemic lupus erythematosus, antiphospholipid syndrome. She has had CNS vasculitis, for which she is on oral Cytoxan and tapering doses of prednisone. She was admitted because of complaints of headache and an episode of dizziness. She denied any new motor or muscular weakness. She has chronic slurring of speech and is getting physical therapy at home and actually appears to be a lot improved since her last visit, which was four months ago. She denied any new complaints of increased slurred speech. She denied any new motor weakness. She has chronic weakness of both her lower extremities.
With physical therapy, the motor power in her upper extremities has been improving. She states that she developed shingles two or three weeks ago, for which she was treated. The patient denied any passing out. She denied any joint pain. No new skin rash. She has had alopecia because of the lupus in the past but seems to be a lot improved. The patient was on Cytoxan 100 mg once a day. She has high MCV of her red blood cells, for which she was seen by Hematology as an outpatient consult. They did not feel that there was any problem with side effects from the Cytoxan.
PAST MEDICAL HISTORY: Systemic lupus along with history of CNS vasculitis, hypertension, antiphospholipid syndrome, asthma, and recurring CVAs in the past.
FAMILY HISTORY: No history of any connective tissue disease like lupus or rheumatoid.
SOCIAL HISTORY: She does not smoke. She does not drink.
ALLERGIES: NKDA.
MEDICATIONS: Prior to admission, she was on Plavix 75 mg, prednisone 5 mg twice a day, metoprolol, Norvasc, Protonix, and Effexor. Cyclophosphamide 50 mg two pills daily.
REVIEW OF SYSTEMS: The patient denied any recent weight gain or weight loss. She did not complain of any increasing fatigue. She does have weakness in her lower extremities and is wheelchair bound. She denied any chest pain or shortness of breath. She denied any abdominal bloating. She is basically being admitted to rule out a new CVA and for evaluation of TIA because she had an episode of headache and some dizziness and had some blurring of vision at that time. She denies any prolonged morning stiffness. She is not complaining of any joint pain or joint swelling related to her lupus. She has had CNS vasculitis in the past. She also had some renal problems, but she has been doing quite well. No Raynaud’s at this time. No mouth or nasal ulcers.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 128/96, pulse 66, respiratory rate 18, and temperature 98.6.
GENERAL APPEARANCE: A (XX)-year-old pleasant female lying comfortably in bed. She is paralyzed from her waist down.
HEENT: Cushingoid facies. Alopecia on her scalp seems to have resolved. No ulcers or sores in the mouth or in the nose. No tenderness on palpation over the temporal artery.
LUNGS: Bilateral breath sounds.
HEART: S1 and S2.
ABDOMEN: Soft.
EXTREMITIES: No edema. She has somewhat limited range of motion of her shoulders, elbows, hips, and knees, primarily due to previous paralysis, with basically no motor power in the lower extremities. She does respond to sensory stimuli. No active synovitis in hands, wrists, and feet.
NEUROLOGIC: The patient is alert and oriented.
LABORATORY DATA: CBC: White cell count 5.2. H&H 12.4 and 35.6. Platelet count 156,000. Chemistries: BUN 17, creatinine 0.8. Liver function tests: AST 18 and ALT 43.
DIAGNOSTIC STUDIES: CT of the brain: Stable noncontrast CT of the brain showing old infarct at the left basal ganglion and left periventricular region and mild periventricular white matter changes. No intracerebral or extracerebral bleed. No evidence of mass effect or midline shift. MRI has been done. Results are not available at this time.
ASSESSMENT AND PLAN:
1. A (XX)-year-old female with known history of systemic lupus erythematosus, antiphospholipid syndrome, on Cytoxan 100 mg a day and prednisone 5 mg twice a day. We will be getting some baseline laboratory studies on her, basically to evaluate her for the lupus activity and also as a safety check for the chemotherapy medications that she is on.
2. Headache and dizziness. She has been evaluated by Neurology. CAT scan did not show much. She has had MRI done, results are still pending. She is being followed by Neurology.
3. Motor weakness, which is a chronic problem, but she seems to be recovering. The patient had alopecia in the past because of the lupus, which seems to have resolved.
4. Hypertension and other medical problems.
5. Cushing’s, which is drug induced. We are trying to gradually taper her off the prednisone. Depending upon her laboratory results, we will go further down on the steroids.
