Audio_Rheu_Let_21

To
Jean Baptiste, MD
232 Hawley Street
Lake Cook, Indiana 60060

Re: Joseph, Smart
Date: 03/22/2006


Dear Dr. Jean:

Thank you again for the referral of your patient who was seen at my office today for consultation on May 21, 2006. The patient as you are aware is a pleasant 43‑year‑old female with no significant past medical history. The patient presents now with a long history of approximately 20 years of arthralgias in her lower back, bilateral knees, and bilateral ankles. The patient has morning stiffness for approximately one-half hour. The patient takes Motrin with mild relief. However, he has developed occasional GI discomfort from the Motrin. The patient has also been treated with Mobic from which she developed hives on occasion. The patient denies any other constitutional symptoms.

PRESENT MEDICATIONS: Motrin p.r.n.

ALLERGIES: She denies drug allergies.

SOCIAL HISTORY: She denies tobacco or alcohol use and is a home-health attendant by occupation.

PHYSICAL EXAMINATION:
Blood pressure is 130/80.
Lungs: Bilaterally clear.
Cardiovascular: Normal S1, S2. No S3. No murmurs, rubs, or gallops.
Abdomen: Positive bowel sounds. Soft and nontender.
Extremities: No clubbing, cyanosis, or edema.

Musculoskeletal exam: No active synovitis in the peripheral joints. There are multiple scattered tender points in the upper and lower back. There is tenderness on palpation of the cervical spine and bilateral thighs.

In summary, the patient is a pleasant 43-year-old female who appears to have fibromyalgia; however, will be referred for further laboratory evaluation to rule out other musculoskeletal conditions particularly rheumatoid arthritis. The patient will now be treated with Ultracet q.12h. on a p.r.n. basis and is encouraged to exercise and return for follow up in five weeks or sooner as necessary.

Once again, I thank you for the referral of this pleasant patient.

Yours truly,