Henry Ford Studies

MEDICATIONS:

1.  Cartia XT.

2.  Fosamax 70 mg a week.

3.  Hydrochlorothiazide 25 mg daily.

4.  Lisinopril 5 mg daily.

5.  Zocor 40 mg a day.

CHIEF COMPLAINT:  Knee pain.

HISTORY OF PRESENT ILLNESS:  Patient is a 78-year-old white female complaining of knee pain for years.  Pain is getting worse.  Now she is unable to work in her garden.  She cannot bend or kneel.  She has difficulty getting out of a chair.  No relief with the use of naproxen sodium or with ibuprofen.  The pain is localized.  Does not radiate.  No numbness or tingling.

REVIEW OF SYSTEMS:  No abdominal pain.  No chest pain.  Occasional swelling in the legs.

PAST MEDICAL HISTORY:

1.  Hemicolectomy for colon cancer 2001.

2.  Hypertension.

3.  Arthropathy of the right hip in 2006 for which the patient received an intraarticular corticosteroid injection.

EXAMINATION:

VITAL SIGNS:  Weight is 157 pounds, blood pressure 136/75, with a pulse of 63, temperature 97.1.

MUSCULOSKELETAL:  No swelling in the joints of the hands, the wrists, the elbows.

EXTREMITIES:  Knees lack hyperextension.  They were cool to touch.  There were no anterior knee effusions.  There is valgus deformity bilaterally.  Joint line is not tender.  No pain with range of motion of the hips.  Fatty tissue about the legs, but no overt edema.

IMAGING STUDIES:  Weightbearing radiographs of both knees were obtained today and reviewed with the patient and her husband.  There is obliteration of the lateral tibiofemoral compartments bilaterally.

IMPRESSION:  Arthrosis, both knees.

MEDICAL DECISION MAKING:  Treat symptomatically.  Prescriptions provided for Celebrex 100 mg daily and Vicodin p.r.n.  Consider arthroplasty.

HF Henry Ford Medical

MEDICATIONS:

1.  Enbrel (start date September 2006) 25 mg twice weekly.

2.  Prednisone 7.5 mg daily.

3.  Actonel.

4.  Allopurinol 300 mg a day.

5.  Glipizide 5 mg a day.

6.  Lipitor.

7.  Plavix.

8.  Plaquenil 200 mg a day.

9.  Darvocet-N 100 p.r.n.

CHIEF COMPLAINT:  “I feel okay.”

HISTORY OF PRESENT ILLNESS:  Patient’s pain in her right groin and thigh has eased.  She notices partial relief with the use of naproxen sodium 220 mg taken on an as needed basis.  Patient has pain in her right knee from time to time with weightbearing activity.  That pain is moderated by rest.

REVIEW OF SYSTEMS:  No weight loss, no cough or shortness of breath.  No injection site reaction associated with Enbrel.

PAST MEDICAL HISTORY:  See my note of January 25, 2008.

EXAMINATION:

VITAL SIGNS:  Weight is 202 pounds, blood pressure 119/67, with a pulse of 67, temperature 98.8.

MUSCULOSKELETAL:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion was performed today.  I found no swelling in the knee, PIPs, or the MCPs today.  No swelling in the wrists.  No nodules at the elbows.

EXTREMITIES:  In the lower extremity, no pain with range of motion of the hips.  There is valgus deformity of both knees.  Right knee is warm to touch when compared to the left.  There are no anterior knee effusions.  No pretibial edema.  No squeeze metatarsal phalangeal joint tenderness.  Joint count swelling and tender today is 0 respectively.

IMPRESSION:  Rheumatoid arthritis with no evidence of inflammatory activity today.

MEDICAL DECISION MAKING:  Patient will continue with her current antirheumatic regimen.

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 Studies Samples

MEDICATIONS:  Ibuprofen p.r.n.

CHIEF COMPLAINT:  Numbness and tingling in the fingers of the right hand.

HISTORY OF PRESENT ILLNESS:  Patient has had numbness and tingling in the fingers of her right hand digits 1 through 3 for several months.  Partial relief with the use of a splint provided by her primary care physician.  However, symptoms persist.  Occasionally awaken her at night.  Symptoms were felt primarily on the palmar aspect of the thumb, second and third digits of the right hand.  Patient occasionally has to shake her hand down to get relief.

REVIEW OF SYSTEMS:  There have been no problems with skin rash on sun exposure this summer.

PAST MEDICAL HISTORY:  Hidradenitis.

EXAMINATION:

VITAL SIGNS:  Weight is 166 pounds, blood pressure 115/72, with a pulse of 82, temperature 97.8.

MUSCULOSKELETAL:  Tinel’s sign is positive on the right hand.  No swelling in the joints of the hands, wrists, elbows, knees, ankles, or feet.  No pretibial edema.

IMPRESSION:  Carpal tunnel syndrome, right.

MEDICAL DECISION MAKING:  EMG requested.

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.