SUBJECTIVE
Mr. Keith is a 45-year-old inmate from Stillwater who was referred by Dr. Quiram for evaluation of fibromyalgia. Mr. Keith has a long history of multiple medical problems, including hypertension, diabetes, hyperlipidemia, gastroesophageal reflux disease, and degenerative disk disease. His history dates back he says to age 12, when he first received the diagnosis of fibromyalgia. This was apparently in the early 90s, by 1998 he had developed diabetes mellitus and by the year 2000 he had a diagnosis of diabetic neuropathy. He states that he has had multiple traumas through his life with several car accidents, a car-train accident, a major head trauma, along with multiple fights with injuries and fractures to multiple smaller bones …show more content…
He is alert and oriented and is pleasant to deal with. HEENT exam reveals no conjunctivitis. No mouth ulcers. There is no facial rash. Neck has normal range of motion though he is limited to some extent by pain in extremes of lateral rotation and extension. There is no lymphadenopathy in the neck and no bruits in his carotids. His anterior chest is free of rash. His heart reveals a regular rhythm with a split first heart sound. There is no murmur appreciated. His lungs are clear to auscultation without wheezes or rhonchi. His abdomen is obese with stretch marks. He has no hepatosplenomegaly. Bowel sounds are normal and there are no bruits in the abdomen. His complete joint exam was performed and findings include the second and third PIPs of the right hand and the second PIP of the left hand which appear to be a very slightly thickened synovium. There is also some bony hypertrophy in these joints and in several of his other small joints of his hands, which leads me to believe this is all secondary to osteoarthritis from past injuries. His range of motion of his right hip is somewhat reduced with external and internal rotation being tender and internal rotation particularly being limited at about 5 degrees. There is no definite synovial thickening in either of his knees or in his ankles. He is somewhat tender over the left suprapatellar bursa on the left knee, but he cannot appreciate any definite synovial thickening or effusion in either knee. The exam of the MTP joints in his feet, again reveals some tenderness but no definite synovial thickening, I can appreciate. The complete tender point exam was performed and he is positive in 12 of the 18 classic tender points. He also has some induration over the right trapezius tender point that is more classic for the trigger points of a myofascial pain syndrome than the tender point of fibromyalgia. Other interesting historical
Mr. Keith is a 45-year-old inmate from Stillwater who was referred by Dr. Quiram for evaluation of fibromyalgia. Mr. Keith has a long history of multiple medical problems, including hypertension, diabetes, hyperlipidemia, gastroesophageal reflux disease, and degenerative disk disease. His history dates back he says to age 12, when he first received the diagnosis of fibromyalgia. This was apparently in the early 90s, by 1998 he had developed diabetes mellitus and by the year 2000 he had a diagnosis of diabetic neuropathy. He states that he has had multiple traumas through his life with several car accidents, a car-train accident, a major head trauma, along with multiple fights with injuries and fractures to multiple smaller bones …show more content…
He is alert and oriented and is pleasant to deal with. HEENT exam reveals no conjunctivitis. No mouth ulcers. There is no facial rash. Neck has normal range of motion though he is limited to some extent by pain in extremes of lateral rotation and extension. There is no lymphadenopathy in the neck and no bruits in his carotids. His anterior chest is free of rash. His heart reveals a regular rhythm with a split first heart sound. There is no murmur appreciated. His lungs are clear to auscultation without wheezes or rhonchi. His abdomen is obese with stretch marks. He has no hepatosplenomegaly. Bowel sounds are normal and there are no bruits in the abdomen. His complete joint exam was performed and findings include the second and third PIPs of the right hand and the second PIP of the left hand which appear to be a very slightly thickened synovium. There is also some bony hypertrophy in these joints and in several of his other small joints of his hands, which leads me to believe this is all secondary to osteoarthritis from past injuries. His range of motion of his right hip is somewhat reduced with external and internal rotation being tender and internal rotation particularly being limited at about 5 degrees. There is no definite synovial thickening in either of his knees or in his ankles. He is somewhat tender over the left suprapatellar bursa on the left knee, but he cannot appreciate any definite synovial thickening or effusion in either knee. The exam of the MTP joints in his feet, again reveals some tenderness but no definite synovial thickening, I can appreciate. The complete tender point exam was performed and he is positive in 12 of the 18 classic tender points. He also has some induration over the right trapezius tender point that is more classic for the trigger points of a myofascial pain syndrome than the tender point of fibromyalgia. Other interesting historical