Audio_Rheu_Let_22

To
Jean Baptiste, MD
14 Northgate
Beach Park, Illinois 11357

Re: Harry, Smart
Date: 08/21/2004


Dear Dr. Jean:

Thank you again for the referral of your patient who was seen at my office today on August 21, 2004 for followup. The patient as you are aware is a pleasant 51‑year‑old female with a past medical history of status post left mastectomy in 1997, hypothyroidism and rheumatoid arthritis diagnosed approximately one year ago. The patient presents now for followup continuing to experience left knee and left hip discomfort. The patient has minimal morning stiffness.

PAST MEDICAL HISTORY: As above.

PRESENT MEDICATIONS: Plaquenil 400 mg daily, Naprosyn 500 mg q.12h. p.r.n., methotrexate 7.5 mg weekly, Zantac 300 mg daily, and folic acid daily.

PHYSICAL EXAMINATION:
Blood pressure is 130/70.
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: The patient has bilateral ulnar deviation in the hands with marked decreased range of motion in the left hip with internal and external rotation.

In summary, the patient is a pleasant 51-year-old female with rheumatoid arthritis as well as marked DJD of the left hip. The patient appears to have increased activity now and would be advised to increase methotrexate to four tablets weekly. The patient in addition is advised that she will require a left hip replacement in the near future and if he is scheduled for an orthopedic evaluation when she is well prepared to have her left hip replaced. The patient is advised to have labs repeated in your office in six weeks and return for followup in two months or sooner as necessary.

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

Yours truly,