Henry Ford Medical Cases

MEDICATIONS:

1.  Enalapril 10 mg twice a day.

2.  Lasix 40 mg a day.

3.  Zantac 150 mg twice a day.

4.  Flonase inhaler.

5.  Celexa 20 mg a day.

6.  Mobic 15 mg a day.

7.  Oxycodone 20 mg a day.

REFERRING PHYSICIAN:  Dr. Todd Lininger.

REASON FOR CONSULTATION:  Evaluate significance of a positive antinuclear antibody test.

HISTORY OF PRESENT ILLNESS:  Patient is a 60-year-old African-American female with chronic musculoskeletal pain for which she is followed in the Pain Clinic at DMC.  Recently, an antinuclear antibody test was found to be positive and the patient is referred to evaluate the significance of that finding.  She was referred to Rheumatology Group at Harbor Hospital, but could not get an appointment until July and she comes to Ford.  She goes to the Pain Clinic for facet injections.

REVIEW OF SYSTEMS:  Patient responds positively to most questions.  She has chronic musculoskeletal pain varying in severity from day-to-day.  No symptoms suggestive of Raynaud’s phenomenon.  No skin rash on sun exposure.

PAST MEDICAL HISTORY:  Hypertension, vitiligo.  Patient may have thyroid disorder, but she reports no one seems to agree on that.

SOCIAL HISTORY:  Patient used to work in Personnel at Ford Hospital.

EXAMINATION:

VITAL SIGNS:  Weight is 215 pounds, blood pressure 119/77 with a pulse of 75, temperature 97.4.

NECK:  No thyromegaly.

MUSC/SK:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion, and deformity was performed today.  I found no evidence of peripheral joint arthritis.  There was depigmentation over the skin of the PIPs and the MCPs.  Patient is able to make a fist.

EXTREMITIES:  No pretibial edema.

FAMILY HISTORY:  No one in the family, which the patient is aware, has lupus.

IMPRESSION:  Positive antinuclear antibody does probably in association with vitiligo may or may not be associated with autoimmune thyroid disease.

MEDICAL DECISION MAKING:  I see no need for additional hematologic testing at the moment.

Patient’s primary care physician is Dr. Angela Bully.

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.

Henry Ford Medical Studies

MEDICATIONS:

1.  Plaquenil 200 mg a day.

2.  Prednisone 5 mg p.r.n.

CHIEF COMPLAINT:  Aches and pains.

HISTORY OF PRESENT ILLNESS:  Patient is getting by all right.  Aches and pains from time to time.  She takes prednisone sporadically.  Patient could not afford Provigil.  However, she reports that with rest her fatigue improves.

SOCIAL HISTORY:  Patient has a job working for the City of Detroit Election Commission in a clerical capacity.

PAST MEDICAL HISTORY:  See my note of January 4, 2008.

EXAMINATION:

VITAL SIGNS:  Weight is 146 pounds, blood pressure 111/65, with a pulse of 69, temperature 97.1.

MUSCULOSKELETAL:  No swelling in the joints of the hands, wrists, elbows, knees, ankles, or feet.

CHEST:  Clear.  No crackles or wheezing.  Heart tones okay.  No precordial rub.

THROAT:  No ulcers on the hard palate.

IMPRESSION:  Lupus with no clinical evidence of disease activity today.

MEDICAL DECISION MAKING:  Prescription provided for Plaquenil and prednisone.  Patient is scheduled an appointment in Gastroenterology to evaluate the persistence of hepatitis C RNA.