Henry Ford Studies

MEDICATIONS:

1.  Cartia XT.

2.  Fosamax 70 mg a week.

3.  Hydrochlorothiazide 25 mg daily.

4.  Lisinopril 5 mg daily.

5.  Zocor 40 mg a day.

CHIEF COMPLAINT:  Knee pain.

HISTORY OF PRESENT ILLNESS:  Patient is a 78-year-old white female complaining of knee pain for years.  Pain is getting worse.  Now she is unable to work in her garden.  She cannot bend or kneel.  She has difficulty getting out of a chair.  No relief with the use of naproxen sodium or with ibuprofen.  The pain is localized.  Does not radiate.  No numbness or tingling.

REVIEW OF SYSTEMS:  No abdominal pain.  No chest pain.  Occasional swelling in the legs.

PAST MEDICAL HISTORY:

1.  Hemicolectomy for colon cancer 2001.

2.  Hypertension.

3.  Arthropathy of the right hip in 2006 for which the patient received an intraarticular corticosteroid injection.

EXAMINATION:

VITAL SIGNS:  Weight is 157 pounds, blood pressure 136/75, with a pulse of 63, temperature 97.1.

MUSCULOSKELETAL:  No swelling in the joints of the hands, the wrists, the elbows.

EXTREMITIES:  Knees lack hyperextension.  They were cool to touch.  There were no anterior knee effusions.  There is valgus deformity bilaterally.  Joint line is not tender.  No pain with range of motion of the hips.  Fatty tissue about the legs, but no overt edema.

IMAGING STUDIES:  Weightbearing radiographs of both knees were obtained today and reviewed with the patient and her husband.  There is obliteration of the lateral tibiofemoral compartments bilaterally.

IMPRESSION:  Arthrosis, both knees.

MEDICAL DECISION MAKING:  Treat symptomatically.  Prescriptions provided for Celebrex 100 mg daily and Vicodin p.r.n.  Consider arthroplasty.

Henry Ford Medical Cases

MEDICATIONS:

1.  Enalapril 10 mg twice a day.

2.  Lasix 40 mg a day.

3.  Zantac 150 mg twice a day.

4.  Flonase inhaler.

5.  Celexa 20 mg a day.

6.  Mobic 15 mg a day.

7.  Oxycodone 20 mg a day.

REFERRING PHYSICIAN:  Dr. Todd Lininger.

REASON FOR CONSULTATION:  Evaluate significance of a positive antinuclear antibody test.

HISTORY OF PRESENT ILLNESS:  Patient is a 60-year-old African-American female with chronic musculoskeletal pain for which she is followed in the Pain Clinic at DMC.  Recently, an antinuclear antibody test was found to be positive and the patient is referred to evaluate the significance of that finding.  She was referred to Rheumatology Group at Harbor Hospital, but could not get an appointment until July and she comes to Ford.  She goes to the Pain Clinic for facet injections.

REVIEW OF SYSTEMS:  Patient responds positively to most questions.  She has chronic musculoskeletal pain varying in severity from day-to-day.  No symptoms suggestive of Raynaud’s phenomenon.  No skin rash on sun exposure.

PAST MEDICAL HISTORY:  Hypertension, vitiligo.  Patient may have thyroid disorder, but she reports no one seems to agree on that.

SOCIAL HISTORY:  Patient used to work in Personnel at Ford Hospital.

EXAMINATION:

VITAL SIGNS:  Weight is 215 pounds, blood pressure 119/77 with a pulse of 75, temperature 97.4.

NECK:  No thyromegaly.

MUSC/SK:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion, and deformity was performed today.  I found no evidence of peripheral joint arthritis.  There was depigmentation over the skin of the PIPs and the MCPs.  Patient is able to make a fist.

EXTREMITIES:  No pretibial edema.

FAMILY HISTORY:  No one in the family, which the patient is aware, has lupus.

IMPRESSION:  Positive antinuclear antibody does probably in association with vitiligo may or may not be associated with autoimmune thyroid disease.

MEDICAL DECISION MAKING:  I see no need for additional hematologic testing at the moment.

Patient’s primary care physician is Dr. Angela Bully.

Henry Ford Case Study

MEDICATIONS:

1.  Celebrex 100 mg daily.

2.  Lasix 40 mg p.r.n.

3.  Valium p.r.n.

CHIEF COMPLAINT:  Right shoulder area pain.

HISTORY OF PRESENT ILLNESS:  Patient is complaining of pain in the right parascapular area and her right shoulder.  Sometimes, the pain will radiate down to her elbow but not below.  Patient also has chronic neck pain.  Patient reports that her symptoms will improve with the use of naproxen.  However, this medication was stopped because of the recent elevation of creatinine, which has since normalized.  Minimal pain relief with the use of Celebrex.  Because of the pain in the right arm, patient is shifting her patient care activities through her left arm.  Patient has pain when she tries to abduct her right arm in the plain of the scapula.

REVIEW OF SYSTEMS:  No abdominal pain associated with the use of naproxen.  No swelling of the legs.

PAST MEDICAL HISTORY:  Left mastectomy for breast cancer.  Craniotomy for repair of a Chiari malformation.  Meniscal surgery right knee.  Episode of thrombocytopenia in 2001 prior to removal of breast implants that were placed after mastectomy.  Scoliosis of the lumbar spine.  Hip dysplasias bilaterally.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Weight is 262 pounds, blood pressure 112/74 with a pulse of 87, temperature 98.2.

EXTREMITIES:  Range of motion of the shoulders did not appear to be restricted, however, impingement maneuvers duplicated some of the patient's symptoms.  External rotation of both shoulders was about 70 degrees and on internal rotation, the patient was able to get her thumb well over the belt line.  There is no subacromial tenderness on palpation.

IMAGING STUDIES:  I was able to see his shoulders in the CT scan of the thorax.  Glenohumeral joint spaces were preserved.

LABORATORY STUDIES:  Serum creatinine on May 17th of this year was 1.1 and on June 12th 0.5.

IMPRESSION:  Rotator cuff syndrome, right shoulder.

MEDICAL DECISION MAKING:  Ultrasound of the right shoulder ordered.  Patient might consider restarting Naprosyn.

Henry Ford Case Studies

MEDICATIONS:

1.  Naproxen sodium 220 mg p.r.n.

2.  Prednisone 5 mg to be taken as 1 or 2 tablets a week.

CHIEF COMPLAINT:  Occasional aches and pain.

HISTORY OF PRESENT ILLNESS:  Patient is getting by alright.  She stopped taking methotrexate.  She noticed no improvement with the juice.  Patient is currently using prednisone and naproxen sodium on an as-needed basis.  Minimal morning stiffness.  No joint pains.

REVIEW OF SYSTEMS:  No weight loss.  No abdominal pain.  No cough or shortness of breath.  No swelling in the legs.

PAST MEDICAL HISTORY:  Patient received methotrexate from September 2006 to about December of 2007 not because of lack of efficacy.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Weighs 192 pounds, blood pressure 131/86 with a pulse of 59, temperature 98.3.

MUSC/SK:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion, and deformity was performed today.  Results were recorded on the articular examination sheet.  I found no swelling in the joints of the hands, wrists, elbows, knees, ankles, or feet.  However, there were flexion contractures of the third PIPs bilaterally, which I could not reduce.  Patient was unable to make a tight fist with either hand because she could not fully bend or flex the PIPs of either hand.

IMPRESSION:  Rheumatoid arthritis characterized by joint damage today rather than by inflammation.

MEDICAL DECISION MAKING:  Patient wants to continue with her current antirheumatic regimen.  Laboratory tests were requested.

HF Henry Ford Medical

MEDICATIONS:

1.  Enbrel (start date September 2006) 25 mg twice weekly.

2.  Prednisone 7.5 mg daily.

3.  Actonel.

4.  Allopurinol 300 mg a day.

5.  Glipizide 5 mg a day.

6.  Lipitor.

7.  Plavix.

8.  Plaquenil 200 mg a day.

9.  Darvocet-N 100 p.r.n.

CHIEF COMPLAINT:  “I feel okay.”

HISTORY OF PRESENT ILLNESS:  Patient’s pain in her right groin and thigh has eased.  She notices partial relief with the use of naproxen sodium 220 mg taken on an as needed basis.  Patient has pain in her right knee from time to time with weightbearing activity.  That pain is moderated by rest.

REVIEW OF SYSTEMS:  No weight loss, no cough or shortness of breath.  No injection site reaction associated with Enbrel.

PAST MEDICAL HISTORY:  See my note of January 25, 2008.

EXAMINATION:

VITAL SIGNS:  Weight is 202 pounds, blood pressure 119/67, with a pulse of 67, temperature 98.8.

MUSCULOSKELETAL:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion was performed today.  I found no swelling in the knee, PIPs, or the MCPs today.  No swelling in the wrists.  No nodules at the elbows.

EXTREMITIES:  In the lower extremity, no pain with range of motion of the hips.  There is valgus deformity of both knees.  Right knee is warm to touch when compared to the left.  There are no anterior knee effusions.  No pretibial edema.  No squeeze metatarsal phalangeal joint tenderness.  Joint count swelling and tender today is 0 respectively.

IMPRESSION:  Rheumatoid arthritis with no evidence of inflammatory activity today.

MEDICAL DECISION MAKING:  Patient will continue with her current antirheumatic regimen.