Audio_Rheu_Hp_17

CONSULTATION NOTE

HISTORY: The patient is a pleasant 66-year-old African-American male with no past medical history, referred for bilateral ankle pain and elevated CK. He states that he gets ankle pain occasionally with weightbearing with mild swelling around the ankles for few months. He denies any muscle weakness, dysphagia or shortness of breath. He denies any rashes, oral ulcers, or Raynaud’s symptoms, photosensitivity, dry eyes, dry mouth. He states that he was on a statin which was discontinued three months ago. He denies any myalgias. He denies any other joint symptoms except for the ankles. He denies any rashes, uveitis symptoms, fevers, chills, weight loss, lymphadenopathy, or shortness of breath. He does admit to mild nonproductive cough, which he has had for few weeks. He denies any recent travel. He denies any HIV risk factors.

PAST MEDICAL HISTORY: Hyperlipidemia.

MEDICATIONS: None.

SOCIAL HISTORY: He denies smoking. Denies alcohol use.

ALLERGIES: No known drug allergies.

FAMILY HISTORY: Noncontributory.

PREVENTIVE MEDICINE: He states that he is up to date with his colorectal screening as well as prostate exams.

PHYSICAL EXAMINATION:
Vital Signs: On exam, his blood pressure is 122/80.
General: He is a well-nourished, well-developed male in no acute distress.
HEENT: There is no heliotrope rash. There is no lymphadenopathy. Throat is clear.
Lungs: Clear to auscultation bilaterally.
Heart: Normal S1, S2.
Extremities: There is no rash. There is no papule. There is no synovitis. His motor strength is 5/5 in both upper and lower extremities proximally and as well as distally. There is some questionable soft tissue swelling around the medial aspect of both ankles without any tenderness, warmth or erythema. He does have pes planus in both feet.

ASSESSMENT: This is a 56-year-old male with bilateral ankle pain and elevated CPK.

PLAN:
1. My suspicion for an inflammatory myositis is not particularly high at this time. However, I will check specific antibodies for completeness. Bilateral ankle pain and elevated CKs may occasionally occur with sarcoidosis and thus I will also check an ACE level and a chest x‑ray. Of note is that he does have symptoms of cough recently.
2. Given his arthralgias and mild leucopenia, I will also check an ANA, Smith and RNP as well as SSA and SSB to rule out SLE. He has had negative double-stranded DNA already.
3. He has been given a prescription for Naprosyn 500 mg once a day with food p.r.n. pain for the ankles, adverse effects of Naprosyn and side effects were discussed with the patient and all questions were answered.
4. I have asked them to followup with me in about four weeks to review the blood work results as well as x-ray.