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.