Dr.

Mary Elsworth
General Practitioner
New Century Medical Surgery
94 Clemency Road
East Melbourne

14 January 2022

Dear Dr. Elsworth,

Re: Ms. Bisma Saleem, aged 17 years.

I am writing to updating you about your patient, Ms. Bisma Saleem, who has been diagnosed with
Systemic Lupus Erythematosus; therefore, she requires regular monitoring and family counselling.

Ms. Saleem presented today with a complaints of facial rash, recurrent oral ulcers, chronic low-grade
fever, fatigue, lethargy, and a frothy foul-smelling urine; in adittion of two months history of weight loss
and two episodes of seizures in the last 24 hours. On examination, she has a butterfly rash in her cheeks,
temporal alopecia, and mild PIP, MCP, and wrist joint swelling, tenderness and redness. Her vital signs
showed a BP of 97/74, pulse was 102, and BMI 18. Please note that laboratoy results confirmed her
diagnosis by reported a presence of positive antibody for ANA, Anti-dsDNA and directed Coombs test.
Additionally, a significant decrease in Hb, WBC and platelets were founded; therefore,
Hydroxychloroquine, prednisone and ibuprofen were commenced.

Given the above, I kindly arranged a follow-up in 7 days to assess Ms. Saleem clinical response and
evaluation for a possible lumbar puncture test, in addition to arragement an appointment for arthrocentesis
and ECHO. Ms. Saleem was adviced on family counselling, a regular monitoring of her electrolytes
balance and seizures episode by her primary doctor.

Please do no hesitate to contact me for further information.

Yours sincerely,

Doctor.