SUBJECTIVE: The patient is a (XX)-year-old female who comes in to follow up on fever and myalgias. The patient was seen in urgent care. She had had two to three days of chills, malaise, and general joint pains, worst in the fingers, knees, elbows, back, and neck. The patient had not documented any fevers and was actually afebrile in urgent care. There was no rash that she noted. She was on vacation when she came down with the symptoms, but had not noted any tick bites prior. She had no ill contacts. She had no upper respiratory infection symptoms or gastrointestinal symptoms associated with this. At urgent care, she had some general blood work. This showed a mild decrease in red blood cell count compared to her physical in May. Hemoglobin was 12, MCV slightly down at 78, WBC count 8.2, potassium a bit low at 3.3. ALT was slightly elevated at 58 and alkaline phosphatase was 94. CRP was 26. Lyme antibody was negative. The remainder of the comprehensive metabolic profile was basically within normal limits. It was felt that she likely had a viral process going on. She was started on naproxen, I believe, 500 mg twice daily as well as ranitidine twice daily, and put in for a followup visit.
The patient comes in today stating she is overall somewhat improved. She has had no recurrence of fever that she is aware of. She still has not developed any rash that she is aware of. Her generalized aches have improved. She is still quite sore and a bit swollen in her hands, knees, and ankles. Pain score is 5/10 compared to 8/10 when she was here Tuesday. She is tolerating the naproxen fairly well and taking it on schedule. She is sleeping okay. She has gone back to work. No one else in the family has come down with any illnesses. She denies any abdominal pain, change in bowel or bladder habits or any new upper respiratory infection symptoms.
PAST MEDICAL HISTORY: Includes mononucleosis, back pain, tension headaches, distant history of abnormal Pap, hypertension, and obesity.
CURRENT MEDICATIONS: Oral contraceptives and hydrochlorothiazide 25 mg, as well as naproxen and ranitidine.
ALLERGIES: No known drug allergies.
HABITS: Tobacco: None.
OBJECTIVE: The patient is an overweight female, in no acute distress, nontoxic. Temperature 97.6, blood pressure 126/88, pulse 74 and regular, weight is 200. Today, pain score is 5/10. There is no facial asymmetry. Sclerae are nonicteric. Oropharynx: Benign. Neck is supple without lymphadenopathy. Lungs: Clear. Heart: Regular rate and rhythm. Abdomen: Soft and nontender. No mass or hepatosplenomegaly appreciated. Hands, she has mild puffiness. She states the pain is most noticeable in the MCP area. There is no major deformity, no erythema or ecchymosis. No rashes noted.
ASSESSMENT AND PLAN: This is most likely a nonspecific viral syndrome. Could be early Lyme, and we are going to repeat her Lyme test in a few weeks; although, she has had no rash. Could also be Parvovirus, although again rash is absent, so cannot be sure of this. We are going to defer testing for this today. She has made progress, is going to continue the naproxen for another four to five days and then discontinue if able. Stop sooner if she has significant stomach upset, get plenty of rest, hydrate well. There is no known family history of any rheumatologic disorders. Her CRP was elevated at 26. We are going to have her return in a few weeks to repeat labs that were abnormal, as well as repeat Lyme testing in about three weeks. She will call sooner if she does not continue to improve or has any worsening of symptoms in which case we can consider ID versus Rheumatology consultation, most likely rheumatologic. She will call as needed, otherwise, and we will contact her as needed regarding results after she comes for repeat blood work.
