Sample Transcribed Reports:

Edited Sample Report

This pleasant **-year-old woman has had low back pain since she was 15 years old. She developed right buttock area discomfort with a tight sensation in the last several years. This comes and goes. She's quite stiff and sore in the morning for half an hour or so. She has difficulty getting a sock on. When she's up and around it does loosen up and doesn't bother her as much. She does have a chronic low grade degree of low back pain, however, tells me lately that this has been less problematic. It is there usually on a daily basis and perhaps monthly she has an increased degree of pain lasting a day or so.

She notes that pulling the garage door produces an aching in her hands perhaps twice, with soreness in the interspace between the first and second digits, more so on the right hand. She's tender if she pokes at this area. She notes that she's tender in the shoulder area if she presses on them but otherwise they don't bother her. She had some soreness in her knees last year when she without a car for three months. At one point her knees were quite swollen for several days. They still feel weak at times. She finds walking for more than half an hour is sometimes uncomfortable and sometimes the knees are sore to straighten out.

She's going through some considerable emotional upset at the moment. She's currently going to the psychiatric day program at ***** Hospital and is halfway through the program. She is troubled by low self esteem, marked shyness and other problems which she's working on.

She's not currently taking any medications other than vitamins. She has concern about some hair loss.

Past History:  Includes a sinus operation three times for some unusual type of polyps. She has had tonsillectomy, wisdom teeth out. She went through a period where she was feeling quite unwell and getting worse, having several courses of antibiotics. She then went to some alternative health care and with that she felt better.

She's married with two teenage children. She's not working currently.

On Exam:  BP was 90/60. Head and neck exam was all clear. Funduscopic examination was normal. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. She has increased lumbar lordosis. She's able to bend forward and touch her toes but her back does not reverse curvature with that. She had no sacroiliac joint tenderness to stressing. She was tender to direct pressure over the lower lumbar spine and sacrum. She had slight tenderness with full range of movement of her right hip. No tenderness on the left. She did not have widespread soft tissue tenderness. She had no tender or swollen joints in the hands. She had no flexor tendon nodules or nodules anywhere else.. She had a full range of movement of her knees and no tender or swollen joints in the feet.

Blood work in October showed ESR of 10, negative ANA, weakly positive rheumatoid factor of 24.

I have called for her lumbar spine x­rays from two years ago.

Impression:  I do not feel that she has fibromyalgia and reassured her. At this point, there's no clinical evidence to support a diagnosis of rheumatoid arthritis.

She has been told that she has degenerative disease in her spine on x­ray, and has been reviewed by a chiropractor as well. I suspect this is the source of her pain in the low back as well as the right buttock area. I will review the x­rays for myself as well.

I have encouraged her to get into a more aggressive exercise program. She has a weight machine at home. I've suggested that she start off with 10–15 minutes of warm up, do some stretching and then go through a routine of both upper and lower body work to try to strengthen her trunk muscles.

I gave her some suggestions such as capsaicin cream.

I have asked her to return for review in four months or so.

Edited Sample Report

Thank you for asking me to see this **-year-old woman who tells me that she has problems with several joints. She complains of swelling, stiffness and pain. She has been stiff in the morning over the summer and fall. She recalls being concerned because she had difficulty holding on to the water­skiing rope because of weakness. The most recent problems began with pain in the right foot after being stepped on in October. This seemed to take much longer than expected. She then developed pain in the right big toe with swelling, marked pain, but no redness. In November, she developed pain in her fingers as well as her shoulders. She could barely grip the steering wheel in the morning. Her bilateral thumb IP joints were painful and slightly swollen in early November. Subsequently, she developed problems with her elbows and knees with pain but no noted swelling. She feels that since she has had an intermittent involvement of the joints with individual joints coming and going.

She has been taking Relafen in the morning. She feels that she limps until about 10:00 a.m. and then loosens up. The best time of day is about 3:00 in the afternoon. She stiffens up overnight and indeed wakes up through the night. At night her left arm, right leg and knees have been bothering her. Three days ago her right wrist was swollen. She gets an intermittently sore neck.

Prior to the Relafen she had tried Naprosyn which didn't help after six weeks.

She has had no oral or nasal ulcers. She may have had a slight increase in hair loss. She denies any chest pain or pleurisy. She has had no Raynaud's. She has had no sicca symptoms.

She had shingles in 1998. She had an arthrodesis of her left ankle in 1997. This was an old injury which had bothered her for years. Since then, the arthrodesis has not been painful. She had a hysterectomy 30 years ago.

She has no allergies. She doesn't smoke. She has alcohol occasionally.

She is trying glucosamine sulfate.

She is a widow. She has *** grown children and *** grandchildren so far.

On Exam:  BP was 176/80. Head and neck exam was all clear. Funduscopic examination was normal. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. She had no palmar or periungual erythema. She had stress pain of the right hand second, third and fourth digit IP joints. She had slight puffiness in the region of the left second and third MCPs with tenderness of the second and third IPs as well as the MCP and tenderness to pressure over the area. She had no flexor tendon nodules or nodules anywhere else.. She had no tenderness or swelling in joints of the wrists, elbows,shoulders, hips, knees or ankles. The left ankle was fused and the ankle and subtalar joint. She had stress pain of the right second MTP joint.

Lab:  Blood work November ** showed ESR of 16, uric acid 278, negative ANA and a weakly positive rheumatoid factor of 22.

Impression:  I would agree that she appears to have early rheumatoid arthritis. I have suggested she try taking the Relafen two tablets in the evening rather than in the morning. This might help her have a more restless sleep overnight and loosen her up first thing in the morning.

She weighs 135 pounds or about 61 kilos. I've suggested that she start Plaquenil 400 mg a day. I explained that this may take several months before we determine whether or not it's going to work.

At the moment, I felt that she did not require low­dose prednisone, but if she gets more sore and stiff , adding 7.5 to 10 mg of prednisone in the morning may make a clinical difference with minimal side effects. The idea would be to continue with the second­line therapy and hopefully get her off the prednisone reasonably quickly.

I've asked her to return for review in about three months, or to call if she's having any problems.