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.