These reports
are samples of basic clinical evaluations of patients seen by a rheumatologist. The sample reports have been checked for
accuracy in spelling, but please keep in mind nobody's perfect, and we do appreciate any notification of errors. These sample
medical reports may also include some styles or report formats that are unusual, and if so, this would be due to the preference
of the dictating physician.
Edited Sample Report
This patient returned to discuss her recent investigations. The lumbar spine film showed that she had a fracture at L1.
She's not aware of having had any previous lumbar spine films to compare with. Although reported as showing moderate compression
of L1, when I looked at these I thought that she had lost 50% of anterior height. Xrays of her pelvis and hips were unremarkable.
Her bone density assessment was actually fairly good with a T score of 1.07 in the lumbar spine and almost in the
middle of the normal range for the femoral neck.
I have sent her for protein electrophoresis today to make sure there is not some other explanation for the fracture. She
has normal thyroid function and normal calcium.
I'm assuming the fracture occurred early in the year when she had the marked increase in back pain after the severe coughing
episode. At this point, I didn't think there was much point in getting a bone scan.
I have suggested that she start Didrocal. This will help to maintain her bone density. The other medications she might
consider would be Reloxifene which has antiestrogen effects on the breast and uterus but positive effects for the bone
and cardiac system.
Edited Sample Report
This patient tells me that she has been doing pretty well; quite a bit better overall, however, does have problems with
her wrists. She also has aching behind the right calf.
She had been taking Plaquenil only intermittently as it was giving her considerable GI upset. She's not taking any antiinflammatories
at the moment. At the most, she was taking Plaquenil half a tablet every once in a while.
Upon examination, she had tenderness in both wrists, decreased range of movement on the left with only about 50% flexion
and extension and slight swelling. She had no other tender or swollen joints.
We talked about options including methotrexate, salazopyrin, and Minocin. She chose Minocin. I've sent her for baseline
blood today and she'll have blood tests monthly while taking the Minocin. She will work up slowly to 200 mg a day. I've gone
over the possible side effects of this and made her aware that she'll require monthly monitoring.
Edited Sample Report
This patient had increased his methotrexate back up to 25 mg per week in the preceding couple of months because of persistent
left knee swelling. His knee had improved with that, but in the short while before coming in for this visit he had noticed
some persistent swelling. His psoriasis, he feels, is not too bad, although he still has some slight patches on the elbows.
Upon examination, his left knee had a moderatesized effusion. This was aspirated for 30 ml of slightly turbid yellow
fluid and 80 mg of Kenalog was injected.
He's going to continue with methotrexate 25 mg per week. If his knee stays settled, he will start gradually tapering the
methotrexate. If, in spite of this, the knee problem returns, he will have some additional therapy added, likely salazopyrin.
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