DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation of arthralgias.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has a history notable for genotype 1 hepatitis C with grade 1 fibrosis, previously treated with pegylated interferon and ribavirin without clinical response after nine months of therapy. The patient is unsure of how she may have contracted it. She describes feeling achy from head to toe. It is frequently associated with nausea, without vomiting and widespread myalgias and arthralgias. The symptoms tend to wax and wane in severity with pain-free days and other days where she feels symptomatic for a few days, where she is essentially bedbound. The patient denies any muscle weakness or soft tissue swelling. She does admit to taking methadone, which is being prescribed by her primary care physician, which does help with her symptoms. No significant sleep disturbance. The patient does admit to feeling depressed and anxious. The patient was seen by Dr. John Doe last month, and he put forth the possibility of new protease inhibitors that she may be a candidate for.
REVIEW OF SYSTEMS: No fever, chills or sweats. Weight has been steady; although, she does admit to some anorexia. Intermittent nausea without vomiting, again arthralgias and myalgias as outlined above. No rashes, Raynaud’s, focal neurologic deficits, hematuria, history of seizure, DVT, miscarriage, cardiopulmonary or genitourinary symptoms. No scleral or conjunctival inflammation, stomatitis or alopecia. The patient does give a history of migraine headaches.
PAST MEDICAL HISTORY:
1. Hepatitis C with grade 1 fibrosis, status post pegylated interferon/ribavirin treatment without response.
2. Depression and anxiety.
3. Migraine headaches.
4. Bilateral elbow fractures.
5. Knee surgery in the remote past.
6. Herniated disk in the past.
MEDICATIONS: Methadone, Ativan, vitamin B12 injections and aspirin.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION:
VITAL SIGNS: Her blood pressure is 108/82, heart rate 72, weight 178 pounds, temperature 97.6. Pain is 6/10.
GENERAL: Her gait is stable and steady. She is a highly anxious female, in no apparent distress.
HEENT: No scleral or conjunctival abnormalities. Oropharynx: Clear without visible lesions. Normal salivary pooling. No parotid or submandibular glandular enlargement.
NECK: Supple without lymphadenopathy.
HEART: Regular, no extra heart sounds.
LUNGS: Clear.
ABDOMEN: Soft, nontender, positive bowel sounds.
SKIN: No active rashes or edema at this time.
NEUROLOGIC: Grossly nonfocal.
MUSCULOSKELETAL: Examination is entirely within normal limits without any active synovitis in the small or large joints. She has good range of motion throughout without chronic deformities, contractures deformity, or laxity. She does not demonstrate any soft tissue tender points on examination today.
LABORATORY DATA: Labs from last year show a normal CBC. Her LFTs, in fact, are normal as well with an AST of 24 and ALT of 34, alkaline phosphatase 84 with an albumin of 4.4. Serologic panel from last month showed no evidence of cryoglobulins, rheumatoid factor negative, antimitochondrial and anti-smooth muscle antibody negative, ANA screen negative. Hepatitis B is negative; however, her hepatitis C PCR was positive.
ASSESSMENT AND PLAN:
1. Longstanding history of nonspecific widespread arthralgias and myalgias. We spent approximately an hour outlining impression at length to the patient today. She is entirely serologically negative with regards to rheumatoid factor, ANA, and cryoglobulins. There is no evidence to suggest cryoglobulinemia at this time. Although, her symptoms are not consistently on a daily basis, we would still tend to favor that her musculoskeletal complaints are likely an underlying manifestation of her hepatitis C, despite the absence of her cryoglobulins. We reassured the patient today that she does not have evidence of inflammatory polyarthritis, nor does she have evidence to suggest muscle weakness or myopathy at this point, as her muscle enzymes have also been in the normal range. At this point, we have urged her to continue with Dr. Doe with regards to additional possible therapeutic agents. She does take methadone, which is being prescribed by her primary care physician and he is managing it at this point. Certainly, nonsteroidal anti-inflammatories may be employed on a p.r.n. basis, but again, she would need to use cautiously and with clearance from Dr. Doe with regards to her underlying liver disease. No additional rheumatologic workup necessary at this time.
2. Hepatitis C. Again, she is discussing alternative treatments with Dr. Doe at this time.
3. Depression and anxiety. Again, ongoing efforts at possible behavioral medicine intervention discussed with the patient, which she will discuss with her primary care physician.
Thank you for asking us to participate in the care of this pleasant patient.
