Henry Ford Case Study

MEDICATIONS:

1.  Celebrex 100 mg daily.

2.  Lasix 40 mg p.r.n.

3.  Valium p.r.n.

CHIEF COMPLAINT:  Right shoulder area pain.

HISTORY OF PRESENT ILLNESS:  Patient is complaining of pain in the right parascapular area and her right shoulder.  Sometimes, the pain will radiate down to her elbow but not below.  Patient also has chronic neck pain.  Patient reports that her symptoms will improve with the use of naproxen.  However, this medication was stopped because of the recent elevation of creatinine, which has since normalized.  Minimal pain relief with the use of Celebrex.  Because of the pain in the right arm, patient is shifting her patient care activities through her left arm.  Patient has pain when she tries to abduct her right arm in the plain of the scapula.

REVIEW OF SYSTEMS:  No abdominal pain associated with the use of naproxen.  No swelling of the legs.

PAST MEDICAL HISTORY:  Left mastectomy for breast cancer.  Craniotomy for repair of a Chiari malformation.  Meniscal surgery right knee.  Episode of thrombocytopenia in 2001 prior to removal of breast implants that were placed after mastectomy.  Scoliosis of the lumbar spine.  Hip dysplasias bilaterally.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Weight is 262 pounds, blood pressure 112/74 with a pulse of 87, temperature 98.2.

EXTREMITIES:  Range of motion of the shoulders did not appear to be restricted, however, impingement maneuvers duplicated some of the patient's symptoms.  External rotation of both shoulders was about 70 degrees and on internal rotation, the patient was able to get her thumb well over the belt line.  There is no subacromial tenderness on palpation.

IMAGING STUDIES:  I was able to see his shoulders in the CT scan of the thorax.  Glenohumeral joint spaces were preserved.

LABORATORY STUDIES:  Serum creatinine on May 17th of this year was 1.1 and on June 12th 0.5.

IMPRESSION:  Rotator cuff syndrome, right shoulder.

MEDICAL DECISION MAKING:  Ultrasound of the right shoulder ordered.  Patient might consider restarting Naprosyn.

Henry Ford Case Studies

MEDICATIONS:

1.  Naproxen sodium 220 mg p.r.n.

2.  Prednisone 5 mg to be taken as 1 or 2 tablets a week.

CHIEF COMPLAINT:  Occasional aches and pain.

HISTORY OF PRESENT ILLNESS:  Patient is getting by alright.  She stopped taking methotrexate.  She noticed no improvement with the juice.  Patient is currently using prednisone and naproxen sodium on an as-needed basis.  Minimal morning stiffness.  No joint pains.

REVIEW OF SYSTEMS:  No weight loss.  No abdominal pain.  No cough or shortness of breath.  No swelling in the legs.

PAST MEDICAL HISTORY:  Patient received methotrexate from September 2006 to about December of 2007 not because of lack of efficacy.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Weighs 192 pounds, blood pressure 131/86 with a pulse of 59, temperature 98.3.

MUSC/SK:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion, and deformity was performed today.  Results were recorded on the articular examination sheet.  I found no swelling in the joints of the hands, wrists, elbows, knees, ankles, or feet.  However, there were flexion contractures of the third PIPs bilaterally, which I could not reduce.  Patient was unable to make a tight fist with either hand because she could not fully bend or flex the PIPs of either hand.

IMPRESSION:  Rheumatoid arthritis characterized by joint damage today rather than by inflammation.

MEDICAL DECISION MAKING:  Patient wants to continue with her current antirheumatic regimen.  Laboratory tests were requested.

Henry Ford Case Study

MEDICATIONS:

1.  Methotrexate (start date January 2008) 10 mg weekly.

2.  Folic acid 1 mg a day.

3.  Acetaminophen.

CHIEF COMPLAINT:  Joint pain.

HISTORY OF PRESENT ILLNESS:  Patient has joint pain.  She felt better when she was taking sulindac.  She claims this was stopped by her primary care physician.  She has morning stiffness for about an hour.  Partial relief with the use of acetaminophen.  Patient appears to be taking methotrexate sporadically.

REVIEW OF SYSTEMS:  No weight loss.  No cough or shortness of breath.  No abdominal pain.  No swelling in the legs.

PAST SURGICAL HISTORY:  Patient was seen by Dr. Lane Scheiber, who is a rheumatologist in the downriver area.  He prescribed sulindac, use of which provided her with modest relief of joint pain.

SOCIAL HISTORY:  Patient’s husband died with carcinomatosis on 15th of May of this year.

EXAMINATION:

VITAL SIGNS:  Weight is 122 pounds (133 pounds in January 2008), blood pressure 133/85 with a pulse of 81, temperature 97.5.

MUSC/SK:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion, and deformity was performed was performed today.  I found swelling in the PIPs, MCPs, and wrists of both hands today.  Knees were warm to touch, but there were no anterior effusions.  No nodules at the elbows.  Joint count swelling today was 17 and joint count tender is 0.

IMPRESSION:  Rheumatoid arthritis in flare.

MEDICAL DECISION MAKING:  Methotrexate 2.5 mg prescribed to be taken as 3 tablets twice a day on Mondays, and sulindac 200 mg to be taken twice a day.  Laboratory tests were requested today.  Return in 8 weeks.

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.

HF Henry Ford Case study

MEDICATIONS:

1.  Methotrexate (start date April 2008) 10 mg weekly.

2.  Folic acid 1 mg a day.

3.  Prilosec 20 mg a day.

4.  Diclofenac sodium gel applied topically to the knee.

5.  Patient is receiving prednisone 10 mg today.

CHIEF COMPLAINT:  “I feel better.”

HISTORY OF PRESENT ILLNESS:  Patient has reduction in morning stiffness.  Joint pain has improved.  Patient has stiffness from time to time and would like to take something for it.  She was advised to stop taking Naprosyn because of stomach upset.  Stomach symptoms have improved with the use of Prilosec.

REVIEW OF SYSTEMS:  No weight loss.  No abdominal pain.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Weight is 151 pounds, blood pressure 139/78 with a pulse of 88, temperature 97.0.

MUSC/SK:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion, and deformity was performed today.  The results compared to the examination documented on the articular examination sheet on March 31, 2008.  In the right hand, there was swelling and tenderness on palpation of the right thumb MCP and tenderness on palpation of the third PIP.  In the left hand, there was swelling and tenderness of the left wrist.  There were nodules palpable along the olecranon process of both elbows but no swelling.  In the lower extremity, the knees were warm to touch but there was no tenderness on palpation.  No anterior effusions.  There is limitation of motion of both ankles.  No squeeze metatarsal phalangeal joint tenderness.  Joint count swollen and tender today was 2 and 3 respectively.  This is in contrast to a joint count swelling and tender of 11 each in March of this year.

Laboratory test results reveal evidence of methotrexate toxicity.

IMPRESSION:

1.  Rheumatoid arthritis with monthly use of methotrexate and prednisone.

MEDICAL DECISION MAKING:  Patient will continue with the current anti-rheumatic regimen.  She reports feeling better when she takes enteric-coated aspirin.  While she is taking Prilosec, I think she could use the aspirin as needed.  Return in 8 weeks.  Prescriptions provided for methotrexate.