Systematic lupus erythematosus

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Reference no: EM133930261

Question

Urology Office Consultation: PROCEDURAL CODING

Reason for Referral: Systematic lupus erythematosus

History of Present Illness: Patient told she had SLE in 1998

Past History: Illnesses: Lupoid hepatitis, 1998. Operations: Renal biopsy. Hepatic biopsy.

Review of Systems: HEENT: conjunctivitis and iritis. Cardiorespiratory: Pleuritic chest pain. Gastrointestinal: Vague abdominal pain. Extremities: Edema.

Physical Examinations: General: Patient 50 year old female with obvious pedal edema. Chest: RRR. Lungs: Clear. Breasts: Normal. Abdomen: Hepatomegaly. No shifting dullness or fluid waves. Extremities: 3+ pitting edema in both lower extremities.

Database: Sodium 135, potassium 4.6, calcium 7.6 phosphorus 2.7, total protein 4.5, albumin 1.9, BUN 25, creatine 1.1, uric acid 5.2, Hemoglobin 13.6, hematocrit 42.1, sedimentation rate: 35, WBCs 5600 with 86 segs, 0 bands, 12 lymphs, MCV 93. The 24-hour urine protein is 10.57 gm, creatine 828 mg, Q-pane: The 5'nucleotidase was elevated at 12.98, antiDNA negative, anticentromere negative, anti-smooth muscle negative, ANA positive at 195, anticardiolipin antibody normal and mitochondrial antibody normal.

Assessment: 1. Abnormal antinuclear antibody positive for lupus. 2. Nephrosis

Recommendations: Nephrology consultation for evaluation of renal status

What is the E/M:___________________

Reference no: EM133930261

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