A 12-year-old female is sent by her primary care physician to see a rheumatologist for a pediatric rheumatology consultation because she was found to have 3+ proteinuria and anemia (Hgb 8.9) after a routine physical exam. A repeat urinalysis on first morning urine specimen had 3+ proteinuria and 1+ blood. Additionally, her antinuclear antibody (ANA) test was 1:2560.
The patient is accompanied to the rheumatologist’s office by her mother, who reports that the child has been more fatigued than normal in the past six months and has had recurring fevers up to 38.60o C approximately one to three times per week for the past two weeks. Her mother also reports that the child has lost five pounds since her previous well-child exam.
The patient has had periorbital edema in the mornings for the past month, which the mother attributed to “allergies.” The patient also reports that her socks often leave indentations above her ankles when she removes them at night, and she reports generalized musculoskeletal pain on most days, which she rated at a 6 on a Faces Scale of 0–10. She especially has pain and stiffness in her hands and sometimes her rings are “too tight,” especially in the morning. The patient has had an intermittent raised red rash across her cheeks for the past three months, which is more prominent when she is outdoors in sunlight, and her mother reports that the child’s hair has been thinning, but denied patchy alopecia.
The patient also reports new-onset, daily frontal and parietal headaches for the past two weeks, which do not wake her from sleep. She rates headaches at 10 on Faces Scale 0–10. Her headaches are sometimes associated with dizziness or photophobia, but she denies nausea or photophobia at this time.
The mother reports that the child seems to be more forgetful recently and that her teachers have reported that she has not been completing her school assignments. The patient reports that she sometimes has difficulty remembering her school assignments. The mother denies that the patient has exhibited any other behavior changes.
The patient also denies oral or nasal ulcers, visual disturbances, swollen or tender lymph nodes, Raynaud’s phenomenon, chest pain, dyspnea, cough, epistaxis, unusual bruising, dysuria, insomnia, tremors, seizures, hallucinations, abdominal pain, vomiting, diarrhea, constipation, or hematochezia.
The patient was premenarche and is not on any prescribed medications, but takes Tylenol for headaches or musculoskeletal pain with occasional relief. She has no known allergies.
Past Medical History: The patient was born at term to a G1P1 mother by normal spontaneous vaginal delivery and had no prenatal or postnatal complications. Her growth and development were normal, with no surgeries or hospitalizations and no comorbidities. Her immunizations are up to date and she had chickenpox at three years of age.
Family Medical History: Significant for rheumatoid arthritis in paternal grandmother, hypothyroidism and migraine headaches in mother, and type II diabetes mellitus in maternal grandfather. No family history of childhood arthritis, lupus, cancer, irritable bowel disorder, psoriasis, or blood disorders.
Social History: The patient lives with her parents and her nine-year-old brother. Pets: one dog. The father is an engineer and the mother is a social worker who works part time. There is no smoking or firearms in home. The patient is in seventh grade and was doing well in school until the past six weeks.
On examination, the patient is alert and oriented to time, place, and person. Her short-term and long-term memory is grossly intact. Her blood pressure is 129/87, her heart rate is 100, her respiratory rate is 20, and her temperature is 36.80o C. Her height is 154.9 cm, her weight is 44.5 kg, and her body mass index (BMI) is 18.5. The head, eyes, ears, nose, and throat exam is remarkable for mild periorbital edema and a small ulcer on the hard palate. The fundoscopic exam is normal. Her skin is slightly pale, with erythematous maculopapular malar rash. There were mildly enlarged, nontender cervical and inguinal nodes. Her lungs are clear, and her heart is regular rate and rhythm with no murmurs or friction rubs. Her abdomen is soft and nontender with no mass or hepatosplenomegaly. Her breasts and pubic hair are early Tanner stage II.
Musculoskeletal exam: The patient’s gait is steady. She has good muscle strength in her upper and lower extremities, both proximally and distally. Her spine shows normal curvature and full range of motion. She has mild swelling and irritability in the right wrist and right 2nd and 3rd proximal interphalangeal joints. All other joints are unremarkable with full range of motion, and there is no evidence of active synovitis. All other deep tendon reflexes are normal.
Diagnoses:
- Proteinuria, anemia, rash, and positive ANA;
- Mild hypertension;
- Headaches and memory difficulties; and
- Probable systemic lupus erythematosus with lupus nephritis.
Plan: There is a lengthy discussion with the mother and patient regarding clinical findings, differential diagnoses, further diagnostic workup, and potential therapies.
Laboratory studies are ordered for lupus evaluation. An MRI/MRA of the brain is ordered to evaluate for central nervous system vasculitis. A nephrology consult is requested and a nephrologist is contacted and arrangements made for the patient to be evaluated later the same day.
The rheumatologist advises the mother that a renal biopsy will probably be needed. She also advises the patient to adhere to a low-sodium diet and provides a diet plan, which is reviewed with both the patient and mother. The patient is also advised to limit sun exposure to the extent that is possible and to use sunscreen with an SPF of 45 or greater when she must be outdoors in sunlight. The mother is advised to call the rheumatologist’s office after the patient sees the nephrologist to review the initial lab results, determine medication therapy, and schedule a followup appointment.
Finally, a report on the clinical findings, impression, and plan is dictated to patient’s primary care provider
How should this encounter be coded?
