HF Henry Ford Case Studies

MEDICATIONS:

1.  Prednisone 40 mg a day.

2.  Colchicine 0.6 mg p.r.n.

3.  Plaquenil 200 mg a day.

4.  Lovenox.

5.  Vicodin p.r.n.

6.  Xanax 1 mg p.r.n.

ADDENDUM TO MEDICATIONS:   

Add Coumadin.  Stop Lovenox.

CHIEF COMPLAINT:  “I was in the hospital.”

HISTORY OF PRESENT ILLNESS:  Patient was in the hospital on the 23rd of May to the 4th of June for treatment of enterococcal bacteremia, the source of which apparently was never determined.  Now, patient reports feeling okay.  Joint pains were minimal.  Patient notices irritability while taking the prednisone.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Weight 165 pounds, blood pressure 129/83 with a pulse of 85, temperature 97.6.

SKIN:  No rash on the face, arms, or legs.

HENT:  No ulcers on the hard palate.

NECK:  No cervical lymphadenopathy.

HEART:  Heart tones were okay.  There may have an S4 gallop rhythm.  No pretibial edema.

MUSC/SK:  I found no swelling in the joints of the hands, wrists, elbows, knees, ankles, or feet.

IMPRESSION:  Lupus appears to be controlled by his current antirheumatic regimen.

MEDICAL DECISION MAKING:  I increased Plaquenil to 400 mg a day.  No hair loss with 200 mg daily.  Continue prednisone at 40 mg a day.  Increase Xanax dose to 2 mg as needed.