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FOLLOWUP NOTE

HISTORY: This is a pleasant 44-year-old female with a history of lupus. Her lupus was diagnosed about eight years ago when she presented with arthritis, rashes and thrombocytopenia and a positive ANA. She denies ever having a history of renal, cardiac, pulmonary or neurological disease from her SLE. Currently, her only complaint is some mild pain on her right shoulder with abduction, which is chronic. She denies any other arthritis symptoms. She denies any oral ulcers, Raynaud’s and serositis symptoms and rashes and photosensitivity, chest pain, shortness of breath or abdominal pain. She does admit to mild alopecia. She denies having any history of any thrombotic events. Recently, she was found to have elevated LFTs on her blood work for which she has an appointment with GI.

PAST MEDICAL HISTORY: SLE and polyps.

MEDICATIONS: Metformin, Aleve, and Pepcid.

SOCIAL HISTORY: She denies tobacco use or alcohol.

ALLERGIES: No known drug allergies.

PHYSICAL EXAMINATION:
Vital Signs: On exam, she appears of stated age in no acute distress with a blood pressure of 110/72.
HEENT: She has a mild malar flush with no oral ulcers or lymphadenopathy.
Lungs: Clear to auscultation bilaterally.
Heart: Normal S1, S2.
Extremities: There is no evidence of synovitis, rash or peripheral edema.

ASSESSMENT: This is a 44-year-old female with systemic lupus erythematosus.

PLAN:
1. At this time her SLE appears stable, and I would recommend to continue clinical surveillance.
2. The patient is reluctant to restart Plaquenil therapy at this time for her SLE and the risks and benefits of this were discussed with the patient.
3. She has elevated LFTs of unclear etiology although she does have a low-titer positive smooth muscle antibody.
4. She is due to followup with GI, and I have told her to discontinue using NSAIDs if she does not need it.
5. She is to return to the office in two months for followup visit. I have also recommended use of sunscreen during the summer since UV light may trigger SLE.
6. Diagnosis, treatment and adverse effects of all medications were discussed with the patient at length and all questions were answered.