REASON FOR VISIT: Problem involving her left thumb.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old right-handed female seen in consultation for a problem involving her left thumb. She states since August, she has had a pain at the base of the thumb. It can bother her if she tries to hold onto something or open a bottle. There is no numbness or tingling. There was never any injury. She did receive a stock splint, but she did not find it useful after trying it for 4 weeks. There is no problem with the right side.
PAST MEDICAL HISTORY: Her major medical issue is emphysema.
PAST SURGICAL HISTORY: She has had a rotator cuff repair on the left side. She has had a cholecystectomy and oophorectomy.
MEDICATIONS: Include bupropion, baby aspirin, citalopram, and calcium.
ALLERGIES: She has had allergic reactions to Depakote.
SOCIAL HISTORY: She is married, living with her husband. She does not smoke. She will have an occasional drink. She enjoys swimming, fishing and running.
FAMILY HISTORY: She has a family history of elevated blood pressure, stroke and arthritis.
REVIEW OF SYSTEMS: Positive for glasses, contact lenses, osteoporosis.
PHYSICAL EXAMINATION: The patient is a very pleasant woman in no acute distress, appearing physically fit at 5 feet 4 inches and 116 pounds. She has good radial pulses, a regular rhythm, and normal rate. She has good range of motion of the shoulders, elbows, wrists, and fingers. She has no significant hyperextension on the left side; she may have 10 degrees on the right side. There is no discomfort at the CMC joint of the right thumb, but she has significant crepitus and a good deal of pain at the CMC joint of the left thumb.
DIAGNOSTIC DATA: X-rays taken recently of the left thumb are reviewed. This shows radial subluxation of the first metacarpal and osteophyte can be seen coming off the metacarpal.
ASSESSMENT AND PLAN: This patient’s problem is left-sided basal joint arthritis. We have reviewed this with her at some length. We have suggested that anti-inflammatory drugs may be of some help. Certainly, they are worth a try. We would also suggest getting a custom-made short opponens splint to see if this works any better than the stock splint she has tried. If these measures are not successful, she would become an excellent candidate for ligament reconstruction with tendon interposition basal joint arthroplasty. The patient is agreeable to try the splints and medication. We will see her back in 2 months though. If she is doing totally fine, the patient may cancel the appointment.
