Consult - History and Phy.
Sample Name: Oligoarticular Arthritis - 2
Description: A lady with symptoms consistent with possible oligoarticular arthritis of her knees.
(Medical Transcription Sample Report)
HISTORY: A is a young lady, who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria. A was worked up for collagen vascular diseases and is here to find out the results. Also was recommended to take 7.5 mg of Mobic every day for her joint pains. She states that she continues with some joint pain and feeling tired all the time. Mother states that also her seizure has continued without any control so far. She is having some studies in the next few days. She is mostly stiff on her legs, neck, and also on her hands. The rest of the review of systems is in the chart.
VITAL SIGNS: Temperature today is 99.2 degrees Fahrenheit, weight is 45.9 kg, blood pressure is 123/59, height is 149.5 cm, and pulse is 94.
HEENT: She has no facial rashes, no lymphadenopathy, no alopecia, no oral ulcerations. Pupils are reactive to accommodation. Funduscopic examination is within normal limits.
NECK: No neck masses.
HEART: Regular rhythm with no murmur.
ABDOMEN: Soft, nontender with no visceromegaly.
SKIN: No rashes today.
MUSCULOSKELETAL: Examination shows good range of motion with no swelling or tenderness in any of her joints of the upper extremities, but she does have minus/plus swelling of her knees with flexion contracture bilaterally on both.
ASSESSMENT: This is a patient, who today presents with symptoms consistent with possible oligoarticular arthritis of her knees with also arthralgias and deficiency in vitamin D. She also has chronic proteinuria and seizure disorder. My recommendation is to start her on vitamin D and calcium supplements, and also increase the Mobic to 50 mg, which is one of the few things she can tolerate with all the medication she is taking. We are going to refer her to physical therapy and see her back in 2 months for followup. The plan was discussed with A and her parents and they have no further questions.
Keywords: consult - history and phy., arthralgias, deficiency, vitamin d, collagen vascular diseases, seizure disorder, vascular diseases, joint pains, oligoarticular arthritis, arthritis, oligoarticular,