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Rheumatology . . . Page 1


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.

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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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