HF Henry Ford News

MEDICATIONS:

1.  Ibuprofen p.r.n.

CHIEF COMPLAINT:  Knee pain better.

HISTORY OF PRESENT ILLNESS:  I saw this patient complaining of right knee pain in April of this year.  At that time, I noticed that the right knee was warm to touch when compared to the left, but there was also tenderness on palpation, but no obvious anterior effusion.  She has noted relief with rest and use of ibuprofen.  Ultrasound of the right knee was unremarkable.  Patient returns today saying that her knee pain has improved.

EXAMINATION:

VITAL SIGNS:  Weight is 186 pounds, blood pressure 121/83 with a pulse of 94, temperature 98.

MUSCULOSKELETAL:  Both knees are cool to touch.  Hyperextension is preserved bilaterally.  No lateral instability.  No anterior effusions.  No tenderness on palpation.  No pain with range of motion of the hips.

IMPRESSION:  Resolving arthropathy, right knee.

MEDICAL DECISION MAKING:  Patient is able to return to work on July 1st.  Currently, she is laid off.  Insurance form is completed.

Henry Ford NEWS

MEDICATIONS:

1.  Atenolol 50 mg daily.

2.  Ibuprofen 800 mg once or twice a day.

3.  Dyazide.

4.  Tylenol No. 3 (prescribed, but not taking).

REFERRING PHYSICIAN: 

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REASON FOR CONSULTATION: 

 Evaluate patient’s complaints of wrist pain and swelling to establish rheumatologic diagnosis.

PATIENT’S CHIEF COMPLAINT:  Generalized aches and pains and swelling of the legs.

HISTORY OF PRESENT ILLNESS:  The patient is a 69-year-old African‑American female seen by Dr. Nwapa in April of this year, where swelling of both wrists was noted for which prednisone in decreasing doses over a period of 10 days was prescribed.  Patient reports that her wrist pain and swelling subsided completely only to return when that medication was stopped.  Now, patient has wrist pain and swelling from time to time.  She also has generalized aches and pains.  She is concerned about swelling in her feet, which she began to notice when she began taking ibuprofen 800 mg once a day.  Ibuprofen also <___> to moderate patient’s symptoms.  Patient is also complaining of numbness and tingling in the fingers of both hands, digits 1 through 3 bilaterally, more on the left then on the right.  She complains of being stiff all over in the morning.

REVIEW OF SYSTEMS:  No abdominal pain associated with the use of ibuprofen.  No headaches.  Back pain from time to time.

PAST MEDICAL HISTORY:  Hypertension.  Patient is currently being worked up for hypercalcemia.

FAMILY HISTORY:  Diabetes and heart disease.

SOCIAL HISTORY:  Patient smoked a pack of cigarettes for about 50 years.  She drinks from time to time.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Weight 149 pounds  Temp.  98.4  BP  98/62  Pulse 75

MUSC/SK:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion, and deformity was performed today.  I found what appeared to be hint of swelling of the dorsal aspect of both wrists, although there was no clear-cut fullness, nor fluctuance.  Wrist extension was about 45 degrees bilaterally.  Tenderness on palpation over the dorsal aspect of both wrists was intermittent.  Traction maneuvers were sometimes painful and sometimes not.  Patient is able to make a fist bilaterally.  No swelling in the DIPs, PIPs nor MCPs.  No swelling of the elbows.  In the lower extremities, no pain with range of motion of hips.  The knees were cool to touch.  No anterior effusions.  No lateral instability.  No pretibial edema.  No swelling of the ankles of the feet.

IMAGING STUDIES:  Radiographs of the hands and wrists were reviewed.  No evidence of chondrocalcinosis articularis.  Weightbearing radiographs of the knees revealed chondrocalcinosis articularis.  No radiographic evidence of arthropathy involving the feet, nor the ankles.  There have been hint of joint space narrowing in both hips, perhaps right more than left in the axial direction.

LABORATORY STUDIES:  Rheumatoid factor screen negative.  Antinuclear antibody screen weakly positive.  Corrected serum calcium level 11 mg/dL.

IMPRESSION:  This patient may have had an episode of inflammatory joint disease; the nature of which is unclear to me.

MEDICAL DECISION MAKING:  I gave the patient a prescription for Medrol Dosepak to use should her knee pain and swelling become more of a problem.  I believe she is experiencing water retention associated with the use of ibuprofen, so I suggested that she take the Tylenol No. 3 that was prescribed and consider the use of naproxen sodium 220 mg, which is available over-the-counter.  She is strongly undergoing of her hypercalcemic condition.

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.