Comes to clinic today to be seen in followup. She has continued complaints of persistent discomfort to the left rib cage, axillary area, radiating up into the neck and jaw. When I had last seen her, I felt that she had a costochondritis, possible fibrositis. I did pursue a workup which included an ANA. All other laboratory work, which included a thyroid function test and basic fasting panel, proved to be negative. Sedimentation rate is borderline elevated at 27. ANA proved to be positive at 1:160. Panel was negative other than 1:400 for antithyroid microsome.
As I was unsure of the significance of these findings, particularly relating to the patient’s symptoms, I recommended she see a specialist for further evaluation. She continues to feel that there is something more severely wrong than just fibrositis or costochondritis. She seems to feel that there is a serious underlying soft tissue problem, although chest x-ray and ECG also proved to be negative. I honestly feel that the patient has fibrositis. I do not believe she has lupus, but given her abnormal laboratory work, I think that it is appropriate to seek referral. I attempted to reassure her and will continue to encourage her to seek a second opinion, via referral, to quiet her anxieties concerning any disease process.
CHART NOTE
The patient is a 39-year-old male with a history of slipped disk. He has had low back pain for approximately 2 years. He had chymopapain which provided temporary relief for his slipped disk. He went back to work, but after 3 weeks he began to have severe low back pain which again radiated down his leg. He claims that the pain is aggravated by coughing or sneezing. He complains of occasional weakness and numbness in the left leg. He also complains of severe pain and discomfort in the right side of his neck and right shoulder, and he has pain when he raises his arm over his head. He denies any redness, heat, or swelling of his joints. He had a recent MRI study, which showed disk space degeneration at L1-L2, L2-L3, L3-L4, L4-L5, and L5-S1, with posterior bulging at L4-L5 and L5-S1. He has a back brace but was told not to use it because it might weaken his abdominal muscles.
Medication consists of Tolectin DS and Fiorinal with codeine. He had a myelogram done in April.
Physical examination reveals a well-developed male in no acute distress. Height 5 feet 6-1/2 inches, weight 174, blood pressure 124/74, pulse 72. Gait and station were normal. Pulses were 2+. There were no temperature changes, ulcerations, brawny edema, or varicosities. Range of motion of all joints was full and within normal limits, except he could only flex his LS spine to 70 degrees and extend it 15 degrees. The remainder of his range of motion was normal. Hand grasp was 4/4 bilaterally, and he could perform fine and gross manipulations with both hands. He walked without assistance. There was no atrophy, heat, swelling, or deformity of his joints. There was tenderness on range or motion of the right shoulder and back. No muscle weakness was noted except for slight weakness on extension of the right leg, but this may be splinting due to his back pain. Reflexes were 1+ and symmetric. Straight leg raising was positive at 60 degrees on the left. There was slight decreased light touch sensation over the left thigh, but light touch was normal distally. There was no evidence of movement disorder, and he was able to ambulate without assistance.
In summary, the patient is a 39-year-old white male with a history of herniated disk treated with chymopapain, with only temporary relief. He continues to complain of low back pain which radiates down his leg, associated with intermittent numbness and weakness.
FOOTNOTE
Lines 34, 36, 44 (Page 1), 25 (Page 2). Alternative: Disc.
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