DATE OF CONSULTATION: MM/DD/YYYY
CONSULTING PHYSICIAN: John Doe, MD
REFERRING PHYSICIAN: Not given.
ATTENDING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: Epistaxis.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old little girl who was in her usual state of good health until last Wednesday when she developed fever. She was given Motrin and Tylenol. On Thursday, her fever broke and she developed epistaxis. The patient had recurrent epistaxis through Saturday and was brought to the ER at this facility because of vomiting coffee-ground. The patient’s hemoglobin was found to be in the 9.2 g/dL range. After admission here, her hemoglobin was found to be in the 7.8 g/dL range, and the patient was transfused. PT and PTT were sent and they are within normal limits. The patient is no longer having any epistaxis.
The patient’s family history is negative for any bleeding diathesis, prolonged menses or requirements for blood transfusion after minor surgery or accidents. The patient eats a normal diet and plenty of green leafy vegetables and meat.
The patient’s MCV is slightly low at 75, platelet count was 245 yesterday and it is 142 today. She had 34 segments, 5 bands, 46 lymphs, 7 monocytes, 1 eosinophil, and 7 atypical lymphs on her peripheral smear. PT is 13.6 and PTT 28.8. The patient’s white count was 6.9 yesterday, hemoglobin 9.6; today, it was 3.1, hemoglobin 7.3, hematocrit 21.8, and platelets 142,000; 32 segments, 11 bands, 52 lymphs, 5 monos, no atypical lymphs. The patient’s complete metabolic panel is entirely within normal limits. The patient’s antibody screen was negative.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is a well-developed and well-nourished girl, in no acute distress. The patient is awake, alert, and interactive on today’s examination.
HEENT: The patient’s head is normocephalic and atraumatic. Extraocular movements are intact. Pupils are equal, round, and reactive to light and accommodation. Sclerae and conjunctivae are within normal limits. Oropharynx is benign. Discs are sharp. Fundi benign. TMs are normal. Normal landmarks. Nasal mucosa is inflamed with dry blood in the anterior nares.
NECK: Neck is supple. No adenopathy or thyromegaly.
CHEST: Clear in all fields, though the patient does have a barking cough.
HEART: Regular rate and rhythm.
ABDOMEN: Abdomen is benign.
SKIN: Skin is without rashes or lesions.
GENITOURINARY: The patient is a Tanner I female.
BACK: No CVA tenderness. No point tenderness along multispinous process. No muscular swelling or tenderness.
No supraclavicular, axillary, inguinal, popliteal or epitrochlear adenopathy.
NEUROLOGIC: Nonfocal, intact.
ASSESSMENT: Upper respiratory infection with probable nonspecific epistaxis.
RECOMMENDATIONS: We will go ahead and do Von Willebrand workup with platelet function assay, factor VIII antigen, factor VIII activity, and ristocetin cofactor. We will stop her Motrin. We will check nasal swabs for influenza A/B and parapertussis.
Thank you for this consult. We will continue to follow this pleasant patient with you. Further recommendations to follow based on results of above-mentioned tests.
