DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Neutropenia and thrombocytopenia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with past medical history significant for hepatitis C virus infection, status post peginterferon therapy a long time ago, status post prednisone treatment which led to exacerbation of his hepatitis C and ultimately was not deemed to be of any benefit. The patient underwent a total hip arthroplasty three years ago and at that time received a course of intravenous gamma globulin without any benefit in terms of raising the platelet count. The patient received platelet transfusion and ultimately went through the surgery. The patient was seen in the attending physician’s office yesterday and was found to have some erythema involving the left hip region, which is the site of the left total hip arthroplasty, and since concerns for cellulitis were raised, the patient was admitted for intravenous antibiotic therapy.
Upon admission, the patient was found to have neutropenia with an absolute neutrophil count of 1300. The patient’s ANC was 1000. The patient’s platelet count has also been low. It was 25,000 on admission and then subsequently, today, was 23,000. Hematology consultation was requested in light of these findings. Upon reviewing the old records, the patient’s platelet count back about three years ago was in the same range at 22,000 and then subsequently at 30,000. The patient had neutropenia in the past as well with a white blood cell count that was close to 3000. The patient denies having any bleeding complications. At this point in time, the patient denies having any fevers.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: As above.
PHYSICAL EXAMINATION: The patient is sitting in the chair and appears to be in no acute distress. Vital signs are stable, afebrile. Head is normocephalic and atraumatic. Pupils are equal, round, and reacting to light. Neck is supple. No JVD. Chest is clear to auscultation. Heart has S1 and S2. Abdomen is soft and nontender. On neurologic exam, no gross neuro deficits. On examination of the extremities, the patient has an area of erythema involving the left posterior hip region at the site of the scar for left total hip arthroplasty.
LABORATORY DATA: WBC count of 2.18 with an absolute neutrophil count of 1000, hemoglobin of 15.2, hematocrit of 44.4, and platelet count of 23,000. PTT 29. INR 1.32. Sodium 134, potassium 4.2, chloride 102, carbon dioxide 26, glucose 110, BUN 10, creatinine 0.8, calcium 8.6, total bilirubin 3.2, alkaline phosphatase 112, ALT 49, and AST 40.
IMPRESSION: Hepatitis C virus infection, likely leading to hypersplenism and subsequently causing neutropenia and thrombocytopenia. We agree with Dr. John Doe that etiology for thrombocytopenia is likely splenic sequestration. The patient has had a trial of intravenous gamma globulins and steroids without any benefit from both these modalities in the past.
RECOMMENDATIONS: Since the patient’s absolute neutrophil count is 1000, we would not recommend any cytokine support at this point in time. Should the absolute neutrophil count drop below 1000, then we would recommend Neupogen 300 mcg subcutaneously daily x2 days. The patient is not bleeding at this time and is in no need of any platelet transfusions. Over the years, the patient’s platelet count has not changed significantly and as such is in no need of any hematologic intervention.
