Bilateral joint pain × 4 months with morning stiffness, facial rash, and frothy urine.
- ●Bilateral joint pain × 4 months, morning stiffness ~90 min
- ●Facial rash over both cheeks × 2 months, worsens with sun exposure
- ●Diffuse hair loss × 3 months
- ●Recurrent oral ulcers, 2-3x/month
- ●Frothy urine × 1 month
- ●Bilateral pedal edema (evening), periorbital puffiness (morning)
- ●Low-grade fever 99-100°F, 2-3 days/week
- ●Left-sided pleuritic chest pain
- ✗No high fever
- ✗No breathlessness
- ✗No prior BP history
(previous — dramatic response, relapsed on stopping)
BP: 148/96 (repeated: 146/94) · B/L pedal edema · Periorbital puffiness · Malar rash bilateral malar distribution · No lymphadenopathy · Chest clear · Abdomen soft
Mentioned in the room but not yet dictated into the note — flagged so nothing said is lost from the record.
- !BP 148/96, repeated 146/94 — no earlier BP history
- !Frothy urine × 1 month
- !Bilateral edema + periorbital puffiness
- !Pleuritic chest pain
- !Steroid responsiveness — relapsed on stopping
Clinical consultation note
ENC #04821 · 8-min consult
C/O bilateral polyarthralgia × 4 months with early morning stiffness lasting ~90 minutes. C/O bilateral malar rash × 2 months, photosensitive. C/O diffuse hair thinning × 3 months. C/O recurrent painful oral ulcers 2–3 times/month. C/O frothy urine × 1 month. C/O bilateral pedal edema, worse in evenings, with periorbital puffiness in mornings. C/O low-grade intermittent fever 99–100°F, 2–3 days/week. C/O left-sided chest pain on deep inspiration.
No high-grade fever. No breathlessness. No prior hypertension.
Previous treatment with Prednisolone 10mg OD — dramatic clinical response with near-complete symptom resolution, relapsed on discontinuation, as reported by the patient.
Family history: Mother — K/C/O hypothyroidism on Thyronorm 50mcg. Sister — on treatment for rheumatoid arthritis.
The impression section carries the physician's words exactly as dictated at the end of the consultation. LIET structures and files them — it does not add, interpret, or suggest clinical content.
Dictated during the consultation, grouped by system, and added to the note for the doctor to check and save.
Nephrology referral. BP review at next visit. Every follow-up decision is the physician's own, captured from the consultation.
This note was generated from a single 8-minute consultation.
From an 8-minute multilingual conversation, a complete structured record — with every decision left to the doctor.