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Make a handwritten note to inform hematology refer

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A realistic, legible handwritten hospital referral note on plain white medical paper, written in blue ink. Exact text: "To, Hematology Team Re: 36-year-old female, known SLE with secondary APS, on immunosuppression. Kindly review for chronic pancytopenia. Latest CBC: Hb 5.6 g/dL, WBC 1.56 ×10³/µL, platelets 124 ×10³/µL. Reticulocyte count 1.6%. Peripheral smear: normocytic normochromic anemia with anisopoikilocytosis; reduced WBCs and platelets. Bone marrow biopsy (09/09/2025): hypocellular marrow with trilineage hematopoiesis and focal dysplasia; reported as possible secondary dysplasia related to SLE. Current treatment: prednisolone taper, hydroxychloroquine, and IV cyclophosphamide. Please advise regarding further hematologic work-up and whether cyclophosphamide should be withheld or continued. Thank you. Name/Signature: __________" Natural clinician handwriting, with clearly spaced lines and no other information.

Handwritten hematology referral note

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To,
Hematology Team
Re: Hematology opinion for chronic pancytopenia in a 36-year-old female
Dear Sir/Madam,
Kindly evaluate this 36-year-old woman, a known case of systemic lupus erythematosus (mucocutaneous, musculoskeletal, and hematological involvement) with secondary antiphospholipid syndrome, for chronic pancytopenia and further management.

Relevant comorbidities

  • Secondary APS with previous SVC thrombosis and collateral formation
  • HFpEF with moderate pulmonary arterial hypertension
  • Ulcerative colitis, biopsy proven in November 2023, currently quiescent
  • Type 2 diabetes mellitus, hypothyroidism, hypertension
  • Antral predominant gastritis

Current clinical status

Currently has possible URTI with fluid retention.
  • Temperature: afebrile
  • Pulse: 98/min
  • BP: 108/68 mmHg
  • RR: 26/min
  • SpO₂: 90% on room air, improving to 94% on 2 L/min nasal oxygen
Respiratory examination: mildly reduced air entry in right lower zone with right-sided crepitations.
Sputum culture: Escherichia coli.

Hematology findings

CBC:
  • Hb: 5.6 g/dL
  • WBC: 1.56 × 10³/µL
  • Platelets: 124 × 10³/µL
  • Hct: 18.4%
  • MCV: 89.7 fL
  • RDW: 17%
  • Reticulocyte count: 1.6%
Previous CBCs:
  • 17/10/2026: Hb 6.0 g/dL / WBC 1.48 × 10³/µL / platelets 122 × 10³/µL
  • 19/10/2026: Hb 6.5 g/dL / WBC 1.68 × 10³/µL / platelets 98 × 10³/µL
Peripheral smear: Normocytic normochromic RBCs with anisopoikilocytosis, few microcytes, occasional macrocytes and tear-drop cells. WBCs and platelets reduced on smear; few large platelets noted. Malarial parasite not seen.
Iron profile:
  • Serum iron: 23 µg/dL
  • TIBC: 134 µg/dL
  • Ferritin: 521.95 ng/mL
LDH 189 U/L, bilirubin normal, and no biochemical evidence provided for active hemolysis.

Bone marrow biopsy, 09/09/2025

  • Hypocellular marrow for age
  • Trilineage hematopoiesis
  • Relative erythroid reduction with dyserythropoiesis
  • Focal dysmyelopoiesis with abnormal localization of immature precursors
  • Increased megakaryopoiesis with focal dysmegakaryopoiesis
  • Reticulin grade 1
  • Impression: possibility of secondary dysplasia due to autoimmune disorder, in view of known SLE

Other relevant investigations

  • USG abdomen: normal-sized spleen; no splenomegaly. Mild ascites.
  • Creatinine: 1.44 mg/dL
  • Urea: 57 mg/dL
  • Albumin: 2.58 g/dL
  • PT/INR: 15 sec / 1.01
  • LFT largely within normal limits except ALP 191 U/L.
  • NT-proBNP: 1663.8
  • 2D echo: EF 60%, moderate PAH.

Immunosuppressive treatment history

  • Rituximab 500 mg on 03/10/2025 and 28/10/2025
  • Rituximab 1 g on 20/04/2026
  • IV methylprednisolone 500 mg for 3 days on 20/07/2026
  • IV cyclophosphamide 500 mg on 24/07/2026
  • MMF stopped after initiation of cyclophosphamide
  • Cyclophosphamide 500 mg IV in 500 mL NS over 3 hours is currently planned/ongoing

Current medications

  • Prednisolone (Omnacortil) 30 mg OD, tapering
  • Hydroxychloroquine 200 mg OD
  • Apixaban 5 mg BD
  • Thyroxine 125 mcg OD
  • Endobloc 5 mg OD
  • Mesacol 1.2 g, 1-0-1
  • Benizep, 1-0-1
  • Nexpro IT, 1-0-1

Request

Kindly advise regarding:
  1. Etiology and further work-up of chronic pancytopenia in this patient with SLE and prior marrow dysplasia.
  2. Need for repeat bone marrow examination, cytogenetics, flow cytometry, or other investigations as indicated.
  3. Supportive management, including transfusion requirements and monitoring.
  4. Safety of continuing IV cyclophosphamide in view of severe anemia and leukopenia, or whether it should be withheld/modified.
  5. Bleeding surveillance and platelet monitoring in view of concurrent apixaban use.
Thank you.
Referring Doctor: ____________________
Date: ____________________
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