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Rheumatology Consult Medical Transcription Sample Report




REASON FOR CONSULTATION:  Evaluation of inflammatory polyarthritis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who was admitted to the hospital with complaints of low back pain that she states has been going on for the past 2 years.  She denies any history of trauma or injury.  She states that she has been hurting in the back for the past 2 years, and lately, the pain has been getting worse.  She denies any prolonged morning stiffness.  She does not complain of any fever or any chills.  There is no prior history of any connective tissue disease or rheumatic disorder.


FAMILY HISTORY:  No history of any connective tissue disease like lupus erythematosus.

SOCIAL HISTORY:  Does not smoke and does not drink.


CURRENT MEDICATIONS:  Aspirin, cyclobenzaprine, tramadol, Novolin, enalapril, amlodipine, metoprolol, bumetanide, Novolin R, and cefazolin IV.

REVIEW OF SYSTEMS:  The patient has been gaining weight over the last several years.  Denies any recent increase in weight or loss of weight.  Does complain of generalized fatigue and weakness.  Denied any fever or any chills.  She has history of coronary artery disease.  Denying any chest pain or shortness of breath at this time.  Denies any abdominal bloating.  Denies any history of skin rashes.  No history of any prior blood clots or deep venous thrombosis.  Musculoskeletal wise, the patient has been experiencing low back pain for the past 2 years.  Denies any joint pain or joint swelling in her hands, wrists or feet.  She has been having difficulty moving her right shoulder joint.  There is no history of any trauma.  Denies any Raynaud's.  No mouth or nasal ulcers.  Denies any hair loss.

VITAL SIGNS:  Blood pressure 132/62, pulse 86, respiratory rate 20, temperature 98.6, and T-max was 100.4.
GENERAL APPEARANCE:  The patient is a (XX)-year-old obese female lying in bed, basically being fed with the help of the nurse.
HEENT:  Pupils equal, round, reactive to light and accommodation.  Extraocular movements intact.  No tenderness on palpation over the temporal arteries bilaterally.
CHEST:  Clear, has bilateral breath sounds.
HEART:  S1 and S2.
ABDOMEN:  Soft, obese, and nontender.
EXTREMITIES:  No pedal edema.  Musculoskeletal examination: Limited range of motion of the right shoulder joint, and left shoulder joint seems to move fine.  She is tender on palpation, likely over the anterior and lateral aspect of the right shoulder joint.  Elbow joints appeared to be fine.  Limited range of motion of the hip joints.  She has crepitus in her knee joints, and on examination of her hands, wrists, and feet, there is some puffiness in her right hand, but there was no tenderness on palpation over the PIP, DIP, and the MCP joints.  Her motor power appears to be decreased in the right upper extremity.  She was unable to move the shoulder joint.  It could be because of pain in the shoulder that she is not able to move the right arm.  No obvious muscular wasting observed.
NEUROLOGIC:  She is alert and oriented.

LABORATORY DATA:  CBC shows white cell count of 14.2, H and H of 9.4 and 29.6, and platelet count 229,000.  Chemistries:  Her BUN is elevated at 54, creatinine 2.6, calcium 9.4.  C-reactive protein is elevated at 13.8.  Sedimentation rate was 94.

DIAGNOSTIC STUDIES:  Chest x-ray shows cardiomegaly without acute infiltrate and thoracic spondylosis.  MRI of the lumbar spine shows presence of significant lumbar stenosis at L4-5 due to degenerative grade 1 spondylolisthesis and severe facet arthropathy with synovitis and enhancement involving the facet joints.  Imaging characteristics are suggestive of a possible osteomyelitis.  Technetium bone scan shows increased activity in the region of posterior superior iliac in the sacral ala bilaterally, of uncertain significance, could represent inflammation.

ASSESSMENT AND PLAN:  The patient is a (XX)-year-old female who is admitted with complaints of low back pain with a history of arthritis in her back for the past 2 years.  Her MRI and bone scan does point towards some inflammatory process going on.  The patient is currently on antibiotics for possible infection.  From the rheumatic aspect, I will be getting some baseline labs on her to rule out any underlying autoimmune or rheumatic disorder.  With a high sedimentation rate, limited range of motion of the right shoulder joint, and the amount of discomfort she has in her back, the possibility of inflammatory arthritis is very high.  At this point, I will be getting an MRI of the right shoulder joint because of decreased mobility.  We will hold off empirical treatment with steroid at least until the initial workup is completed in view of high suspicion of infection.  She does not give typical features of polymyalgia rheumatica.  The patient is also being worked up to rule out any underlying malignancy.  Her blood cultures have been negative so far, not showing any growth after one day.

I will be following the patient with you.  Thank you for the consult.