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.