Henry Ford Medical Studies

MEDICATIONS:

1.  Plaquenil 200 mg a day.

2.  Prednisone 5 mg p.r.n.

CHIEF COMPLAINT:  Aches and pains.

HISTORY OF PRESENT ILLNESS:  Patient is getting by all right.  Aches and pains from time to time.  She takes prednisone sporadically.  Patient could not afford Provigil.  However, she reports that with rest her fatigue improves.

SOCIAL HISTORY:  Patient has a job working for the City of Detroit Election Commission in a clerical capacity.

PAST MEDICAL HISTORY:  See my note of January 4, 2008.

EXAMINATION:

VITAL SIGNS:  Weight is 146 pounds, blood pressure 111/65, with a pulse of 69, temperature 97.1.

MUSCULOSKELETAL:  No swelling in the joints of the hands, wrists, elbows, knees, ankles, or feet.

CHEST:  Clear.  No crackles or wheezing.  Heart tones okay.  No precordial rub.

THROAT:  No ulcers on the hard palate.

IMPRESSION:  Lupus with no clinical evidence of disease activity today.

MEDICAL DECISION MAKING:  Prescription provided for Plaquenil and prednisone.  Patient is scheduled an appointment in Gastroenterology to evaluate the persistence of hepatitis C RNA.