HF Henry Ford Case Studies

MEDICATIONS:

1.  Norvasc.

2.  Dyazide.

3.  Metformin.

CHIEF COMPLAINT:   

Pain in the right leg.

HISTORY OF PRESENT ILLNESS :  Patient is 65-year-old white male, seen as an added patient today.  Patient complained of pain and swelling in his right leg.  Ultrasound revealed no evidence of venous thrombosis on that side.  Patient saw Dr. Bishnoi on June 6.  I reviewed her clinic notes which report pitting edema in the right leg, but no evidence of peripheral joint arthritis.  Patient’s pain and swelling are getting worse and so I am seeing him today in Dr. Bishnoi’s absence.

PAST MEDICAL HISTORY :  Significant for mycosis fungoides.

EXAMINATION :

VITAL SIGNS :  Weight is 178 pounds, blood pressure 131/79, with a pulse of 97, and temperature of 97.

MUSCULOSKELETAL :  There is pitting edema of both legs, more so on the right than on the left.  There are bilateral knee effusions, more pronounced on the right than on the left.  Right knee is warm and tender on palpation.

PROCEDURE :  Diagnostic and therapeutic arthrocentesis of the right knee was performed today using a 1-inch long 18-gauge needle attached to a 10 mL syringe in a lateral approach to the superior pouch after cleansing the skin with Betadine and using ethyl chloride for anesthesia.  20 mL of watery red tinged fluid was removed and 80 mg of Depo-Medrol and 5 mL was Xylocaine was instilled.

Synovial analysis using compensated polarizing light microscopy revealed many leukocytes, none of which contained intracellular crystals.  Leukocytes appeared to be active and then there were pseudopodia and were heavily granulated.

Laboratory studies reveal absence of rheumatoid factor and antibodies CCP.

ADDENDUM TO PHYSICAL EXAMINATION:  I examined the patient’s chest and back in which I could see patchy areas of erythema may have been slightly raised with ill-defined borders, some of which were scaling.  More pronounced on the back than on the front.

IMPRESSION:  Inflammatory joint disease in the setting of what appears to be active mycosis fungoides.

MEDICAL DECISION MAKING:  Follow up with Dr. Bishnoi at Sterling Heights.  Follow up with Dermatology.