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Rheumatology . . . Page 3


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This patient recently started to walk again. She had stopped because of increased pain. Up until a few years ago she had been fairly active. She has been doing some exercises more recently with physiotherapy.

On Exam:  BP was 100/60. Head and neck exam was all clear. Funduscopic examination was normal. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. She had no tender or swollen joints in the upper or lower limbs. She had no soft tissue tender points or trigger points. She had a full range of movement of her lumbar spine. She was able to bend over and touch the floor easily. Straight leg raising was 90º. Deep tendon reflexes were 2+ and symmetric in the upper or lower limbs. She had a full range of movement of her hips. She had no sacroiliac stress pain. She had full extension of the spine. Leg lengths were equal. She was able to squat to the floor and up again easily. On direct pressure over the lower lumbar spine, she was tender over L4 and L5.

Lab:  Recent CBC was normal. TSH was normal. X­rays of her lumbar spine show partial sacralization at L5 but apparently no significant degenerative disease. I did not review these films. She had films of her neck from **** of ****, sent along. These look normal.

Impression:  By history she has mechanical back pain. I reassured her that there was no evidence of either fibromyalgia or active rheumatoid arthritis.

My recommendation is that she get back into a regular and consistent exercise program. I suggested that she try some capsaicin ointment to her low back.

There is no evidence of any significant neurologic involvement at this point. I did not think she required any further investigation.

I haven't arranged any follow­up at this point, but would be happy to reassess at your discretion.

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Edited Sample Report

Thank you for asking me to see this **-year-old woman.

History:  The patient tells me that her left knee had gotten swollen in early August and she was found to have a ruptured Baker's cyst. The knee has remained sore since. She had ten sessions of physiotherapy.With this her left arm became sore and her left neck bothered her from using an exercise bicycle. She noted that just prior to the onset of her problems she had a complete physical and had no joint complaints.

Currently, her left shoulder is the most problematic. She was having difficulty reaching around behind to do up her bra or do any reaching. She found it sore to even watch TV.

She tried acetaminophen which upset her stomach. She has not tried any anti­inflammatories as far as she could recall. She had been taking Robaxacet in the last year because her hands cramped up when she does her hair. They have been doing this for several years.

Other past history includes cataract surgery three times. She had a hysterectomy and previous bladder suspension. She has had a cholecystectomy. She had excision of a tumor under the angle of her jaw. She has had a rash to Imodium. She doesn't smoke or drink alcohol.

Current medications include cimetidine 600 mg twice daily. She's taking lorazepam, 1½ tablet at bedtime and has been taking these for years. She intermittently uses Tavist for her sinus problems.

On Exam:  BP was 150/80. She is a very spry **-year-old. Head and neck exam was all clear. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. Musculoskeletal exam disclosed Heberden's nodes bilaterally but these were not tender. She had a prominent right first CMC joint, however, had an old wrist fracture in that wrist. She did not have CMC squaring on the left. She had a full range of movement of her right shoulder. The left shoulder was restricted with glenohumeral abduction limited to 80ºand internal and external rotation of about 50º. She had a small effusion of the left knee. She was able to flex it only to about 90º.

I have sent her to get an x­ray her left shoulder. Her more recent blood work included normal CBC. ESR was 22. Uric acid was 298, well below the saturation range for gout. ANA was weakly­positive at 40, likely not clinically relevant. Rheumatoid factor was negative. She had a Doppler ultrasound done that showed no evidence of a venous obstruction but she did have a Baker's cyst and the scan suggested a ruptured cyst. X­ray of the left knee was reported as showing demineralization but no significant degenerative disease.

Given the involvement of at least two joints, I suggested that she try Arthrotec 50 mg twice daily. If that doesn't work, she's going to try Naproxen, 375 mg twice daily.

If these don't seem to be helpful or upset her GI tract, I've suggested that she consider returning for injection of her shoulder, knee, or both, in the next month or so.

Her pattern of involvement is, at this point, not really characteristic of any specific joint disease. At her age, however, it is possible for rheumatoid arthritis to start in a gradual fashion such as this and it will be interesting to see how she progresses in the coming months. There's insufficient evidence to suggest that she be on any second­line drugs.

Although she has Heberden's nodes, her lack of radiologic evidence of significant osteoarthritis in the knee seems to me to make it unlikely that that would be the sole cause of her current problems, but that does remain a possibility. It is possible, as she suggested, that she has some early OA in the left knee and has had some secondary tendonitis in the shoulder with development of a stiff shoulder.

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