Rheumatology Consultation Sample Report



HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female seen in consultation regarding possibility of vasculitis. She was admitted with cough and shortness of breath. Her problems began one day after she delivered a baby. The next day, she developed red lesions on the left side; these became palpable and raised. She has a picture on her cell phone where the lesions look a bit like isolated erythema nodosum. The lesions eventually turned into blood blisters and then ulcers. There are currently two lesions on the left side, on the lip and neck.

The patient saw her internist and saw Rheumatology, who did labs. The patient recalls being told that she had a positive rheumatoid factor, but she did not know what other labs were drawn. She was told she had a nonspecific vasculitis and started on 60 mg of prednisone. This was two weeks ago. Beginning the next day, she developed her cough and dyspnea. This progressively worsened to the point where she could barely breathe, and she came to the ER and was admitted.

She has a headache, but this is only related to her cough. She does note small amounts of hemoptysis. She has no sinus blood. She notes no change in her vision or hearing and has no ocular inflammation or stomatitis. She denies alopecia. She has no chest pain other than that associated with coughing, and she has no abdominal pain or diarrhea.

She has lost weight and is currently 15 pounds less than her prepregnancy weight. She has no focal or proximal weakness and no paraesthesias. She never had a malar rash or photosensitivity. She has not experienced Raynaud phenomenon. She has been on 60 mg of prednisone since two weeks ago and was admitted on that dose.

PAST MEDICAL HISTORY: Notable for questionable gestational diabetes, a motorcycle accident in the past with skull fracture and small CNS bleed. She has no history of peptic ulcer, chronic kidney disease, asthma, seizures, anemia or pleurisy.

CURRENT MEDICATIONS: Flexeril, omeprazole, Lovenox, azithromycin, meropenem, prednisone 20 t.i.d. was decreased to 20 b.i.d. last night, and fluconazole 400 mg IV daily was added. She is also on Vicodin and Dilaudid.

ALLERGIES: No known medical allergies.

FAMILY HISTORY: Father is alive and well. Mother is alive, status post myocardial infraction. There is no family history of rheumatoid arthritis or lupus.

SOCIAL HISTORY: The patient is married. She had a baby who died shortly postpartum and has one adopted son. Her three-month-old son is healthy. The patient does not smoke or drink, and she works at a computer.

LABORATORY DATA: CT scan of the chest showed miliary nodules. Followup CT scan showed progression of the nodule with some airspace opacity and small mediastinal lymph nodes. ANA is negative, sed rate is 90, CRP is 24, HIV is negative, INR is normal, albumin 2.2, globulin 5.3, ALT is 104, creatinine 0.8, H and H 10.4 and 32 with a white count of 25,000 and 292,000 platelets.

GENERAL: The patient had been afebrile until yesterday when she had a T-max of 101.6.
HEENT: No scleral or conjunctival inflammation. Oral mucosa is moist without lesions.
NECK: Supple without lymphadenopathy or thyromegaly. Carotid upstrokes are 2+, and there is no salivary gland swelling or tenderness.
LUNGS: Base greater than apex rales and rhonchi.
HEART: Tachycardic with heart rate of 134 but regular with no obvious murmur.
ABDOMEN: Nontender with no mass or organomegaly. Distal pulses are 2+.
NEUROLOGIC: Grossly intact, including intact strength.
SKIN: Notable for healing ulcers on the leg, two on the lateral left side with eschar. There are few small scattered pustules. The right lip has a healing eschar and the left neck has a healing eschar; otherwise, the skin is normal. Her joints are also normal with no synovitis, deformity or decreased range of motion.

ASSESSMENT AND PLAN: This is a (XX)-year-old female with a question of vasculitis. Her lesions seem a bit atypical for vasculitis but could represent a medium-vessel vasculitis. The patient also has pulmonary infiltrates but no renal inflammation, which would be expected with both granulomatosis with polyangiitis and microscopic polyangiitis to increase her immunosuppression.

We would require an open lung biopsy, but as of last night, Pulmonary canceled the pending open lung biopsy. Lowered the dose of prednisone and started fluconazole. There is also on the chart a printout regarding Cryptococcus gattii. It therefore seems that Pulmonary seems relatively certain that the patient is suffering from a fungal infection.

We will try and speak with Dr. Jane Doe as well as Rheumatology. We will also check antineutrophil cytoplasmic antibodies, urinalysis, cryoglobulins and hepatitis B and C.

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