SUBJECTIVE: The patient is a pleasant (XX)-year-old female who comes in for followup of arthritis, right hand. This has improved dramatically with prednisone 10 mg b.i.d. The patient is not on the medication now for approximately two weeks. We had discussed with the rheumatologist about this case, and the rheumatologist believes that this most likely represents pseudogout. We would tend to agree with this, especially since all of her serology results came back negative.
The patient’s other issue is blood pressure, which again is somewhat high today, systolic wise. The patient has not been checking her blood pressures at home lately, so we have recommended she start doing so again on a regular basis. If BPs are high, the patient will call us.
At this point, we think we can taper the prednisone down to 10 mg daily x3, and then stop. If the pseudogout recurs, the patient does have prednisone on hand that she can start and then she will follow up with us here in the office.
OBJECTIVE: The patient is alert, oriented, conversant, and relaxed. Musculoskeletal: The patient’s right hand looks good. Vital signs include blood pressure of 170/74 and heart rate of 88.
ASSESSMENT: Pseudogout, right hand, improved dramatically.
PLAN: As above. Also, full medicine list includes hydrocodone/APAP 5/500 mg one daily, amlodipine 10 mg daily, aspirin 325 mg daily, pravastatin 40 mg daily, and omeprazole 20 mg daily. The patient’s next appointment will be in four months.
SUBJECTIVE: The patient is a very pleasant (XX)-year-old female who comes in today to establish care. She has a main concern of allergy symptoms, which are refractory to use of Claritin. The patient says that her allergies are usually seasonal outside; although, year-round she can have allergic rhinitis symptoms when she goes into her basement or dusty areas.
The patient notes in the past she has used Allegra and Nasonex with better relief. She does not have refills for that medication at this time from her previous PCP. The patient describes symptoms of sneezing, blocked ears, sore throat, itchy eyes. She denies any shortness of breath or wheezing. She denies any nighttime cough. The patient is a lifelong nonsmoker.
The patient has had atypical chest pain with negative cardiac echo, common migraine, generalized anxiety disorder, and recurrent sinus infections.
OBJECTIVE: On exam, vital signs are temperature of 97.8 degrees, weight of 112 pounds, height of 5 feet 3 inches. The patient is a well-developed, well-nourished female in no acute distress. HEENT: Normocephalic, atraumatic. Extraocular muscles intact. Sclerae are anicteric. Tympanic membranes are clear bilaterally with the right one slightly bulging, but no fluid noted. Nares are slightly boggy on the left greater than the right with some fluid present that is nonpurulent. Oropharynx is clear with no injection, exudate; although, the tonsils are slightly enlarged bilaterally. Neck: Supple with no lymphadenopathy. No thyromegaly. No carotid bruits. Lungs: Clear to auscultation bilaterally. No rales, wheezes or rhonchi. Cardiac: Regular rate and rhythm. No murmurs, rubs, or gallops.
ASSESSMENT AND PLAN: Allergic rhinitis: We will switch the patient over to fexofenadine and fluticasone spray. We are also going to give her some naphazoline ophthalmic solution for her eye symptoms. If she does not have complete relief with this, we can consider adding Singulair. However, at that point, I think it will most likely be appropriate to refer her to Allergy and Immunology.
