Labs show normal inflammatory markers

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Reference no: EM134021312

Question

How do you write HPI for Patient recent lab results received and discussed with spouse, her labs show normal inflammatory markers (ESR and CRP), as she has rheumatoid arthritis and takes Methotrexate Sodium 2.5 MG Oral Tablet, so no adjustment in the Methotrexate Sodium 2.5 MG Oral Tablet is needed. But her kidney function is mildly reduced (eGFR 64-78 mL/min/1.73 m²), placing her in CKD stage G2-G3a, and she has markedly elevated vitamin B12 (>1500 pg/mL) and folate (>23.7 ng/mL) levels require immediate investigation to exclude underlying hematologic malignancy or other serious conditions. Will discontinue her folate supplement and the practitioner will continue to monitor and follow-up as needed. All of the patient's spouse questions were answered, and he demonstrated full understanding.

Reference no: EM134021312

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