


Record date: ****-**-**

 
 
 
Mr. ******** is seen today.  I have not seen him since ********. 
About three weeks ago he stopped his Prednisone on his own because
he was gaining weight.  He does feel that his shoulders are
definitely improved.  It is unclear what he is actually taking, but
I think based on the color of his pills and the timing of the
medication that he continues taking his Atenolol for hypertension
and 1 Hydroxychloroquine tablet.  He is concerned because of the
relatively recent onset of difficulties turning his head to the
right.  When he does this, he will note that he feels as though he
is going to pass out although this has not actually happened.  This
only occurs when he turns to the right and not to the left.  He has
no visual changes otherwise and denies any headache or other
cranial complaints.  
 
On examination today, BP 120/80.  He has no bruits over the
carotid.  He has no tenderness in this region either.  He has good
peripheral pulses at the arms.  His joint examination is much
improved with better ROM of the shoulders and no peripheral joint
synovitis.  
 
Clinical Impression:
 
#1:  Inflammatory arthritis - possibly RA - with response noted to
Hydroxychloroquine along with Prednisone.  He has stopped the
Prednisone, and I would not restart it yet.  
 
#2:  New onset of symptoms suspicious for right-sided carotid
disease.  Will arrange for carotid ultrasound studies.  Patient
advised to call me if he develops any worsening symptoms.  He has
been taking 1 aspirin per day prophylaxis long-term, and I stressed
that he continue to do so.  He will follow-up with me shortly after
the ultrasound study.
 
 
 
******* *. *******, M.D.
XGT:******
 
DD: **/**/**
DT: **/**/**
DV: **/**/**
          Approved but not reviewed by Attending Provider         




