HF Henry Ford

MEDICATIONS:

1.  Ibuprofen.

2.  Naproxen sodium p.r.n.

CHIEF COMPLAINT:  Joint pain.

HISTORY OF PRESENT ILLNESS:  Patient is a 53-year-old white male, complaining of pain in the hands, shoulder, low back, and occasionally in the knees.  He is concerned that he might have an arthritic disorder.  Morning stiffness is minimal.  Joint pains could be aggravated by weightbearing activities and relief with rest.  On occasion, he requires a heating pad for low back pain which can last all day.  Sometimes, this is aggravated when he wears leaded material to protect himself from x-ray exposure while performing angiograms.  Patient has stiffness from time to time in his fingers.  This is not interfered with his manual dexterity.

REVIEW OF SYSTEMS:  There is no burning on urination.  No weight loss.  No cough or shortness of breath.  No abdominal pain associated with the use of nonsteroidal antiinflammatory drugs.  No history of rash to suggest the presence of psoriasis.

PAST MEDICAL HISTORY:  Bilateral carpal tunnel releases done arthroscopically in 1992, fracture of the proximal humerus of the left shoulder, injury to the rotator cuff.

NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  Patient is a vascular surgeon.  He went to Medical School at Wayne State University.  Worked at the VA Hospital in Detroit for about 5 years and now is working at Harper Hospital.  He is married to a radiologist who works here at Ford Hospital.  They have 2 sons, ages 24 and 27.

FAMILY HISTORY:  A paternal grandfather had ankylosing spondylitis.  His father had both rheumatoid arthritis and osteoarthritis.  He underwent bilateral hip replacement surgery.  He is unfamiliar with his mother’s side of the family.  He has 1 brother and 3 sisters.  Brother has hand problems and he has a sister who has “myositis”.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Weight is 229 pounds, blood pressure 140/88 with a pulse of 83, and a temperature of 98.1.

MUSC/SK:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion, and deformity was performed and the results recorded on the articular examination sheet.  In the upper extremity, there was bony enlargement of DIPs 2 through 5 on the right and #2 on the left.  No swelling in the PIPs nor the MCPs.  Patient was able to make a fist bilaterally.  No swelling in the wrist.  No flexion contractures at the elbows.  There is limitation of motion of the left shoulder when compared to the right.  There is global limitation of motion of the cervical spine.  In the lower extremities, there appears to be limitation of motion of the right hip when compared to the left.  Internal rotation was about 10 degrees on the right and 15 degrees on the left.  Faber maneuver, however, was not restricted.  Knees were cool to touch.  No anterior knee effusions.  No joint line tenderness.  No lateral instability.  No pretibial edema.  No swelling in ankles or feet.  No dactylitis.  No evidence of psoriasis involving the skin of the legs, nor arms, nor back.  Schober revealed a 5 cm distraction of a 10-cm line.

CHEST:  Clear.  No crackles or wheezing.

HEART:  Tones are okay.  No gallop rhythm and no murmur.

IMAGING STUDIES:  Radiographs of the hands and wrists, feet, anterior and posterior view of the pelvis and weightbearing radiographs of the knees were obtained today and reviewed with the patient.  There is evidence of joint space narrowing in both hips, right more than left, in a superior direction.  Minimal joint space narrowing in the knees.  Joint space narrowing across the DIPs of both hands, right more than left.  There is also evidence of arthropathy involving the thumb bases bilaterally right more than left.  No radiographic evidence of sacroiliitis.

IMPRESSION:  Dr. Granke has findings, which in my view, represent osteoarthritis involving at least 3 joint sites including DIPs, thumb bases, and hips.

MEDICAL DECISION MAKING:  Controlled pain by level of activity and over-the-counter analgesics.  Return to Rheumatology as needed.