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FOLLOWUP NOTE

HISTORY: The patient is a pleasant 46-year-old female with a history of SLE that was diagnosed about one year ago when she presented with symptoms of polyarthritis, oral ulcers, alopecia and pleurisy along with positive serologies for lupus. At present, she denies any joint pain, or swelling or serositis, alopecia, oral ulcers, rashes, photosensitivity or Raynaud’s symptoms. She denies any edema, chest pain, or shortness of breath. She was recently told of protein in the urine. She is currently on Imuran 200 mg a day, prednisone 10 mg a day and Plaquenil 200 mg b.i.d. She was also recently told of positive cardiolipin antibodies although she does not have any history of thrombotic events and she is currently taking aspirin daily.

PAST MEDICAL HISTORY: SLE.

MEDICATIONS: Prednisone 10 mg a day, Imuran 200 mg a day, Plaquenil 200 mg b.i.d., Actonel 35 mg once a week, aspirin q.d., and Prilosec 20 mg a day.

SOCIAL HISTORY: Occasional smoking, no alcohol.

ALLERGIES: No known drug allergies.

FAMILY HISTORY: Positive family history of SLE.

PHYSICAL EXAMINATION:
Vital Signs: On exam, she is no acute distress. Blood pressure is 120/80 mm Hg.
HEENT: There is no rash, oral ulcer, or lymphadenopathy.
Lungs: Clear to auscultation bilaterally.
Heart: Normal S1, S2.
Extremities: Mild fullness at third MCP of left hand. There is no acute synovitis. There is no rash. There is trace pedal edema in bilateral lower extremities.

ASSESSMENT: This is a 46-year-old female with lupus.

PLAN:
1. Continue with Imuran at 200 mg a day.
2. Continue with Plaquenil 200 mg b.i.d. and prednisone at 10 mg a day.
3. She has a history of positive anti-cardiolipin antibodies in the past without any thrombotic events and I have recommended that she continue to take aspirin every day.
4. I have asked her to followup with ophthalmology for visual field testing while on Plaquenil therapy.
5. I would like to check labs including CBC, CMP, UA, double-stranded DNA, C3 and C4.
6. She states that she was recently told of proteinuria on her UA. If there is evidence of protein on repeat UA, we will also refer her to nephrology.
7. Side effects of medications including Imuran, prednisone and Plaquenil were discussed with the patient and all questions were answered.
8. I have also recommended that she continue to take calcium with vitamin D and Actonel while she is on prednisone therapy and that she also use sunscreen regularly.
9. I have asked her to followup in about six weeks or sooner if there are new problems.