Henry Ford Medical Case Study

MEDICATIONS:

1.  Glipizide.

2.  Insulin.

3.  Vicodin.

CHIEF COMPLAINT:  Aches and pains.

HISTORY OF PRESENT ILLNESS:  Patient is 54-year-old African-American female complaining of aches and pains.  She is complaining of numbness and tingling in her fingers of the right hand.  She has back pain.  She has pain in her buttocks.  Pain in her legs from time to time.  Patient wants a shot because she felt better after a shot given to her by Dr. Haggins in January of this year.

EXAMINATION:

VITAL SIGNS:  Weight is 118 pounds, blood pressure 107/67, with a pulse of 72, temperature 97.1.

MUSCULOSKELETAL:  No swelling of the joints of the hands, wrists.  Tinel’s sign negative.  Range of motion of the hips was not restricted.  Knees were cool to touch.  No anterior effusions.  There is lumbar scoliosis with prominence of the lumbar musculature on the left.

IMAGING STUDIES:  Radiographs of the pelvis reveal what appears to be joint space narrowing superiorly in both hips.

ADDENDUM TO PHYSICAL EXAMINATION:  There is tenderness on palpation about the parascapular blades, the posterior superior iliac spine, the trochanteric areas.

IMPRESSION:  Regional pain syndromes.  Possible carpal tunnel syndrome.

MEDICAL DECISION MAKING:  Gave the patient an injection of Depo‑Medrol intramuscularly, right buttock.  Patient may need EMG and a referral to Plastic Surgery, if appropriate for management of carpal tunnel syndrome.  Patient probably has fibromyalgia.