DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Thrombocytopenia.
HISTORY OF PRESENT ILLNESS: This is a (XX)-month-old boy who began having fevers and diarrhea five days ago. He saw his primary care physician. They placed him on some decongestant/antitussive for upper respiratory infection. The fever continued as well as the diarrhea, and the mom brought the patient to the emergency department. At that time, a CBC was obtained, which showed white count of 6500 with lymphocytosis and a normal platelet count. Hemoglobin was 11.9. This morning, his white count is 10,500, hemoglobin 11.9, and hematocrit 34.4 with a platelet count of 12,000. He had 6 segs, 12 bands, 76 lymphs, and 4 atypical lymphs. He has not had history of weight loss. Family history is negative for lupus, autoimmune diseases, arthritis, cancer, and heart disease.
PHYSICAL EXAMINATION: This is a well-developed, well-nourished male who appears his age of (XX)months and is easily arousable. His conjunctivae are mildly injected. Sclerae are anicteric. Oropharynx is benign. Neck is supple with shotty anterior cervical adenopathy. Chest is clear in all fields. Heart is regular rate and rhythm without murmur, rub or gallop. Abdomen is soft, nontender, nondistended. No hepatosplenomegaly, normoactive bowel sounds auscultated, and no masses palpated. Extremities are warm and well perfused without clubbing, cyanosis or edema with uniform full range of motion in all joints. Genitourinary: Tanner I male. Testes down. No mass. There is no CVA tenderness. Skin is without rash or lesions. No point tenderness is noted along the lumbar spinous processes. There is no evidence of musculoskeletal swelling or tenderness. Neurologic exam shows appropriate tone and reflexes for a child this age.
IMPRESSION AND PLAN: The patient is Rh-positive. WinRho was ordered this morning at 75 mcg/kg. That was given this morning. We have explained the pathophysiology and the natural history of immune thrombocytopenic purpura to the patient’s mother. We indicated we would watch him overnight, and that once the platelet count started rising, he could be discharged but would have to follow up in the office at least once per week. If he does not respond to the WinRho, we told her that we would try intravenous immunoglobulin. We will see what his platelet count does over the next couple of days. We also indicated that since baby is now toddling, he will need to stay here as a precautionary measure to make sure that he did not have any head injuries that might result in intracranial bleeding.
