General Internal Medicine Intake

Subjective:
Chief Complaint:
CC: Bilateral wrist and foot pain.

History of Present Illness:
HPI:

Alex is a 15-year-old male presenting with a two-year history of wrist and foot pain. The wrist pain has been persistent and has impacted his ability to engage in activities such as drumming, sports, and video games. He has a history of pes planus for which orthotics were prescribed, resulting in significant improvement in foot pain. He has been taking naproxen and gabapentin as needed, along with Tylenol in the morning. Recently, a trial of aspirin in the evening has reportedly provided significant relief. There is no history of synovitis or other inflammatory symptoms, and serological tests, including rheumatoid factor, CCP antibody, ANA, HLA-B27, and inflammatory markers, have been negative. The patient has a history of hypermobility and previous injuries, including a boxer fracture and thumb dislocation. Family history is notable for conditions such as migraines, myofascial pain syndrome, and depression. An MRI of the wrists is pending, and the patient has been referred to pediatric neurology for assessment of a tremor.

Past Medical History:
PMH: Alex has a history of asthma, for which he has used salbutamol and fluticasone inhalers. There is no other significant history except for some asthma.

Past Surgical History:
PSHx: No past surgical history provided.

Family History:
FHx:  Mother, Maria, has a history of migraines, myofascial pain syndrome, depression, and anxiety. Father is healthy with a history of depression. Maternal grandmother has osteoarthritis, osteoporosis, myofascial pain syndrome, and unspecified nerve problems. Siblings are healthy; sister is noted to be very flexible and participates in gymnastics.

Social History:
SHx: Alex is a student. He has a remote history of classroom assistance. He regularly plays the drums for approximately 10-15 minutes, three times daily. He uses his hands significantly for activities such as video gaming. There has been a decrease in social interactions and participation in sports, video games, and cadet activities due to pain. Drumming activity has been self-tapered.

The Review of Systems:
 Constitutional – no Fever, Chills, Weight Loss, Weight Gain, Night sweats, Fatigue, or Weakness Eyes – no double vision, no blurry vision, wears glasses
 ENT – no Hearing loss, dizziness, runny nose, nose bleeds,
Skin: -  – no rashes, lesions, dry skin, or eczema Cardiovascular – no chest pain, heart palpitations, dizziness Respiratory – no shortness of breath, no cough, no wheezing Endocrine – No known thyroid issues, no changes to appetite, no weight change, no tiredness/lethargy Gastrointestinal – No nausea, vomiting, diarrhea, or constipation. No problems swallowing. No abdominal pain or bloating.
Genito Urinary – no Dysuria, hematuria, frequency, urgency, or nocturia
Musculoskeletal – + wrist joint tenderness to palpation, no redness or swelling 
Neurological – No headaches or weakness, no history of seizures. The patient does not describe any symptoms of carpal tunnel syndrome 
Psychology – No changes in mood, possible hx anxiety and depression as noted per Pediatrics
Hematology – Denies easy bruising, no surgical excess blood loss, no hx VTE

Current Medications:
Meds: 
Naproxen 500 mg orally twice daily. 
Gabapentin as needed. 
Acetaminophen 500 mg orally in the morning. 
Acetylsalicylic acid 325 mg orally in the evening (recent trial).

Allergies:
Allergies:  No known allergies to drugs.

Objective:
Vital Signs:
Height: 5 feet 6.5 inches. Weight: 178 pounds. 

Physical Examination:
 General – Appears well, no obvious discomfort 
Cardiovascular – as reported in peds exam, Heart rate regular, S1S2 normal with no murmurs or added sounds, peripheral pulses easily palpable, equal and symmetric
Respiratory – Lungs clear to auscultation bilaterally with no wheezes or crackles, normal symmetrical chest expansion.
Skin – No rashes, no dry skin, no skin infections, mild facial central cheek flushing noted similar to uulerythema without hair eyebrow loss
Abdomen – deferred
Musculoskeletal – No evident synovitis of large joints. Full range of motion in fingers. Dislocation of left first distal interphalangeal joint. History of right boxer fracture of fourth and fifth metacarpals and thumb dislocation. Generally hypermobile. Head-to-wall distance is normal. Tenderness to percussion over both wrists. No tender, swollen, warm, or erythematous joints. No muscle tenderness. I was unable to determine any clinical synovitis or warmth on examination to date. Beighton Score 2/9
Neurological – Fine tremor noted in hands at rest. EOMI and known nystagmus. Finger-to-nose testing borderline but able to meet targets. No ataxia, coordination intact
.

Test Results:
Serology has shown negative findings which include negative rheumatoid factor, CCP antibody, ANA, negative HLA-B27, negative celiac antibodies, normal inflammatory markers, normal thyroid function, and normal CBC blood counts. The patient has been assessed by ophthalmology with normal findings. MRI of bilateral hands and wrists is pending.

Assessment:
Clinical Impression:
Alex presents with bilateral hand and wrist pain, mild hypermobility of fingers,  and a fine tremor of unclear etiology. There is a history of finger joint instability, and previous injuries. No clinical evidence of synovitis or inflammatory arthritis on examination. MRI and ultrasound imaging are pending to further evaluate for possible arthritis or synovitis.

Differential Diagnosis:
I suspect multi-factorial including one or several of the following:
 1. Joint hypermobility syndrome with associated instability and overuse injuries 
 2. Tendinopathy related to repetitive hand use 
 3. Scapholunate instability 
 4. Juvenile idiopathic arthritis (less likely given negative serology and absence of synovitis) 


Plan:
MSK complaints:
 - Order bilateral ultrasound of the wrists to assess for active synoviti
 - MRI of bilateral hands and wrists pending 
 - Continue referral to pediatric neurology for tremor assessment T

 Treatments: 
- Continue acetaminophen 500 mg orally in the morning as neede
- Continue acetylsalicylic acid 325 mg orally in the evening 
- Discontinue naproxen 
- Monitor for gastrointestinal symptoms; consider empiric angiotensin II receptor blocker if symptoms develop 

Patient Education: 
We- discussed the possible relationship of symptoms to hypermobility and overuse. Pain is specific and focused, it was not my impression he has CPRPS. Mood was appropriate--he is a kid who is unable to fully participate due to symptoms,

Follow Up: -Follow up after imaging results are available or sooner if symptoms worsen