MEDICATIONS:
1. Ibuprofen.
2. Naproxen sodium p.r.n.
CHIEF
COMPLAINT: Joint pain.
HISTORY OF
PRESENT ILLNESS: Patient is a
53-year-old white male, complaining of pain in the hands, shoulder, low back,
and occasionally in the knees. He is
concerned that he might have an arthritic disorder. Morning stiffness is minimal. Joint pains could be aggravated by
weightbearing activities and relief with rest.
On occasion, he requires a heating pad for low back pain which can last
all day. Sometimes, this is aggravated
when he wears leaded material to protect himself from x-ray exposure while
performing angiograms. Patient has
stiffness from time to time in his fingers.
This is not interfered with his manual dexterity.
REVIEW OF
SYSTEMS: There is no burning on
urination. No weight loss. No cough or shortness of breath. No abdominal pain associated with the use of
nonsteroidal antiinflammatory drugs. No
history of rash to suggest the presence of psoriasis.
PAST MEDICAL
HISTORY: Bilateral carpal tunnel
releases done arthroscopically in 1992, fracture of the proximal humerus of the
left shoulder, injury to the rotator cuff.
NO KNOWN DRUG
ALLERGIES.
SOCIAL
HISTORY: Patient is a vascular
surgeon. He went to Medical School
at Wayne State University. Worked at the VA Hospital in Detroit
for about 5 years and now is working at Harper Hospital. He is married to a radiologist who works here
at Ford Hospital. They have 2 sons, ages 24 and 27.
FAMILY
HISTORY: A paternal grandfather had
ankylosing spondylitis. His father had
both rheumatoid arthritis and osteoarthritis.
He underwent bilateral hip replacement surgery. He is unfamiliar with his mother’s side of
the family. He has 1 brother and 3
sisters. Brother has hand problems and
he has a sister who has “myositis”.
PHYSICAL
EXAMINATION:
VITAL SIGNS: Weight is 229 pounds, blood pressure 140/88
with a pulse of 83, and a temperature of 98.1.
MUSC/SK: A complete peripheral joint evaluation for
swelling, tenderness on palpation, limitation of motion, and deformity was
performed and the results recorded on the articular examination sheet. In the upper extremity, there was bony
enlargement of DIPs 2 through 5 on the right and #2 on the left. No swelling in the PIPs nor the MCPs. Patient was able to make a fist
bilaterally. No swelling in the
wrist. No flexion contractures at the
elbows. There is limitation of motion of
the left shoulder when compared to the right.
There is global limitation of motion of the cervical spine. In the lower extremities, there appears to be
limitation of motion of the right hip when compared to the left. Internal rotation was about 10 degrees on the
right and 15 degrees on the left. Faber
maneuver, however, was not restricted.
Knees were cool to touch. No
anterior knee effusions. No joint line
tenderness. No lateral instability. No pretibial edema. No swelling in ankles or feet. No dactylitis. No evidence of psoriasis involving the skin
of the legs, nor arms, nor back. Schober
revealed a 5 cm distraction of a 10-cm line.
CHEST: Clear.
No crackles or wheezing.
HEART: Tones are okay. No gallop rhythm and no murmur.
IMAGING
STUDIES: Radiographs of the hands and
wrists, feet, anterior and posterior view of the pelvis and weightbearing
radiographs of the knees were obtained today and reviewed with the patient. There is evidence of joint space narrowing in
both hips, right more than left, in a superior direction. Minimal joint space narrowing in the
knees. Joint space narrowing across the
DIPs of both hands, right more than left.
There is also evidence of arthropathy involving the thumb bases
bilaterally right more than left. No
radiographic evidence of sacroiliitis.
IMPRESSION: Dr. Granke has findings, which in my view,
represent osteoarthritis involving at least 3 joint sites including DIPs, thumb
bases, and hips.
MEDICAL DECISION
MAKING: Controlled pain by level of
activity and over-the-counter analgesics.
Return to Rheumatology as needed.
