September 8, 2010

Janet Henderson, M.D.

35 Broad Street
Keyport, NJ 07735
(732 888!"1"#
RE: SHANNON BURD
MRN#: 4579207
DOB: 10/14/1975
Dear Dr. Henderson$
%&an' yo( )or a**o+,n- me to part,.,pate ,n t&e .are o) yo(r *o/e*y pat,ent. 0s yo( 'no+, Ms.
B(rd ,s a p*easant 3"!year!o*d )ema*e +,t& a &,story o) r&e(mato,d art&r,t,s and ),bromya*-,a
d,a-nosed 5 years a-o +&en s&e +as .omp*a,n,n- o) 1o,nt pa,n ,n/o*/,n- &er ),n-ers, +r,sts,
e*bo+s, &,ps, and 'nees. S&e &ad .&ron,. pa,n )or many years, b(t ,n Jan(ary o) 2002, s&e
started e3per,en.,n- pa,n ,n &er &ands +&,.& spread to ,n/o*/e &er s&o(*ders and *o+er ba.'.
S&e &ad o..as,ona* pa,n ,n,t,a**y, b(t &as been &a/,n- .onstant pa,n a** t&e t,me. 4t &as
+orsened pro-ress,/e*y. S&e e3per,en.es o..as,ona* atta.'s +&ere s&e ),nds &erse*) (nab*e to
+a*' be.a(se o) -enera*,5ed pa,n. S&e &as pa,n ,n &er ba.' and arm m(s.*es. %&e pa,n ,s
a.&,n- and .rampy ,n nat(re. 4t started -rad(a**y +,t& no tr(e e/ent asso.,ated +,t& morn,n-
st,))ness t&at *asts )or 15 to 30 m,n(tes. %&e pa,n ,s *ess ,n t&e morn,n- and ,ts -ets +orse *ater
on d(r,n- t&e day. 4t -ets better +,t& rest and med,.at,on. 4t ,s +orse +,t& a.t,/,ty. S&e
e3per,en.es o..as,ona* s+e**,n- t&at *asts 1 to 2 days. 4t &appens 3 to " t,mes a +ee'. S&e
states &er symptoms are +orse on t&e r,-&t more t&an t&e *e)t s,de. S&e does not s*eep +e** and
does not )ee* rested ,n t&e morn,n-. Her pa,n ,s .onstant a** day and not +orse ,n t&e morn,n-.
6a,n a** o/er. %&e pa,n ,s 8710 ,n ,ntens,ty. 8yr,.a +as -,/en, be)ore ,t (sed to &e*p, no+ no
re*,e) +,t& met&otre3ate or H(m,ra. S&e &as been on 6*a9(en,*. S&e &as tr,ed m(*t,p*e d,sease
mod,)y,n- a-ents +,t& m,n,ma* re*,e) ,n.*(d,n- H(m,ra, met&otre3ate, as +e** as m(*t,p*e ant,!
,n)*ammator,es, as +e** as 0ra/a.
6ast Med,.a* H,story$ H,story o) 8yme d,sease, &ypertr,-*y.er,dem,a, r&e(mato,d art&r,t,s,
),bromya*-,a, and depress,on.
RE: SHANNON BURD
September 8, 2010
6a-e 2 o) 3
6ast S(r-,.a* H,story$ None.
Med,.at,ons$ 6*a9(en,* 200 m- t+,.e a day, :e**b(tr,n ;8 150 m- da,*y, <))e3or 150 m- a.m.
and =75 >m- p.m., K*onop,n 0.5 m- b.,.d., and )o*,. a.,d 1 m- da,*y.
0**er-,es$ S(*)a and eryt&romy.,n .a(ses ????? and d,)),.(*ty breat&,n-.
So.,a* H,story$ No a*.o&o*, smo',n-, or 4@ dr(- ab(se. S&e ,s s,n-*e. S&e (sed to +or' ,n
.&,*d.are, b(t ,s .(rrent*y (nemp*oyed.
Aam,*y H,story$ Bn'no+n. %&e pat,ent +as adopted.
Ce/,e+ o) Systems$ 6os,t,/e dry eyes. 6os,t,/e dry mo(t&. No ora* (*.ers. No Cayna(d. No
s',n ras&. 6os,t,/e p&otosens,t,/,ty +,t& 6*a9(en,*. S&ortness o) breat& on +a*',n-. Dard,a.
+or'(p ,s ne-at,/e. No abdom,na* pa,n. No na(sea, /om,t,n-, no (r,nary .omp*a,nts. No
m(s.*e +ea'ness. 6os,t,/e &eada.&es, +,t& m,-ra,ne 20 years a-o. Ha,r )a**s )or t&e past 5
years s,n.e start,n- 6*a9(en,*.
6&ys,.a* <3am,nat,on$ B*ood press(re 122780, p(*se 8", temperat(re #8.3, +e,-&t 1#2.3
po(nds, and &e,-&t 5 )eet " ,n.&es. Eenera**y, s&e ,s a moderate*y!b(,*t )ema*e ,n no apparent
d,stress, .&eer)(*. S',n$ :arm and dry. No e/,den.e o) s',n ras&. H<<N%$ 6(p,*s are e9(a*,
ro(nd, and rea.t,/e to *,-&t and a..ommodat,on. <3trao.(*ar m(s.*es are ,nta.t. No pa**or, no
,.ter(s, no p&aryn-ea* eryt&ema. Ne.'$ S(pp*e. No J@D, br(,ts, or *ymp& nodes. D&est$
B,*atera* a,r entry e9(a*. Heart$ S1, S2 re-(*ar. No m(rm(rs, -a**ops, or r(bs. 0bdomen +as
so)t, nontender, nond,stended. 6os,t,/e bo+e* so(nds. Sp,ne e3am,nat,on$ A(** ran-e o)
mot,on .er/,.a*, t&ora.,., *(mbosa.ra* sp,ne. @as.(*ar$ No peda* edema. 6os,t,/e per,p&era*
p(*ses. Ne(ro*o-,.a**y s&e ,s a*ert, a+a'e, and or,ented 33. Motor po+er ,s 575 b,*atera* (pper
and *o+er e3trem,t,es. 4nta.t sensat,on, ,nta.t deep tendon re)*e3es. M(s.(*os'e*eta*
e3am,nat,on$ %&e pat,ent &as pos,t,/e tenderness ,n m(*t,p*e art,.(*ar and nonart,.(*ar s,tes.
Drep,t(s ,n t&e b,*atera* 'nees. %&ere ,s no syno/,t,s. S&e &as )(** ran-e o) mot,on o) a** 1o,nts.
M(*t,p*e tenderness po,nts o) ),bromya*-,a. No sp,na* tenderness, no ????? 1o,nt tenderness and
no ????? m(s.*e +ea'ness or tenderness.
ASSESSMENT AND PLAN
1. H,story o) r&e(mato,d art&r,t,s. %&e pat,ent &as been &a/,n- symptoms o) pa,n ,n
m(*t,p*e 1o,nts d,a-nosed +,t& r&e(mato,d art&r,t,s )or 5 years. S&e &as morn,n- st,))ness. S&e
&as pa,n a** o/er +,t& morn,n- st,))ness o) 30 m,n(tes. :e +,** e/a*(ate &er r&e(mato,d art&r,t,s
by -ett,n- a p*a,n 3!ray o) t&e b,*atera* &ands to e/a*(ate )or any eros,/e 1o,nt d,sease. :e +,**
.&e.' a +&o*e body bone s.an to *oo' )or any ,n)*ammatory 1o,nt d,sease as t&ere ,s no syno/,t,s
on p&ys,.a* e3am,nat,on. :e +,** a*so .&e.' *abs ,n.*(d,n- a r&e(mato,d )a.tor, DD6 s.reen,n-,
0N0, <SC t&erapy, a &epat,t,s pane*, S1o-ren ant,bod,es, as +e** as .omp*ement ant,!Sm,t&,
do(b*e stranded DN0, as +e** as /,tam,n D *e/e*. %&e pat,ent ,s to ta'e ????? 50 m- per day to
RE: SHANNON BURD
September 8, 2010
6a-e 3 o) 3
&e*p .ontro* &er symptoms. :e +,** see t&e pat,ent ba.' ,n 3 +ee's to d,s.(ss +,t& &er t&e 3!
rays as +e** as t&e *ab res(*ts and to e/a*(ate d,sease mod,)y,n- a-ents. S&e ,s to .ont,n(e
6*a9(en,* pend,n- &er *ab and 3!ray res(*ts.
2. A,bromya*-,a. %&e pat,ent &as m(*t,p*e tender po,nts, 18718 tender po,nts +,t& (nrest)(*
s*eep and )at,-(e +,t& a.&es and pa,ns a** o/er. :e +,** .&e.' a %SH and /,tam,n D *e/e* +&,.&
may -,/e some o) &er symptoms. :e +,** a*so start t&e pat,ent on A*e3er,* 10 m- da,*y as a
m(s.*e re*a3ant as +e** as p&ys,.a* t&erapy and a*so +e +,** r(*e o(t ????? ),bromya*-,a as
r&e(mato,d art&r,t,s.
3. S,..a symptoms. %&e pat,ent &as dry eyes and dry mo(t&. :e +,** e/a*(ate t&e pat,ent
)or e/,den.e o) any S1o-ren syndrome. :e +,** .&e.' an ant,!SS0, SSB, as +e** as 0N0 +&,.&
may a..ompany r&e(mato,d art&r,t,s.
S,de e))e.ts o) ????? +as d,s.(ssed +,t& t&e pat,ent ,n deta,*. :e +,** see t&e pat,ent ba.' ,n 3
+ee's )or )(rt&er e/a*(at,on.
%&an' yo( )or a**o+,n- me to part,.,pate ,n t&e .are o) yo(r *o/e*y pat,ent.
S,n.ere*y,
0manda Bor&am, M.D.
0ss,stant 6ro)essor o) Med,.,ne
D,/,s,on o) C&e(mato*o-y
Donne.t,/e %,ss(e Cesear.&
Cobert :ood Jo&nson Bn,/ers,ty Hosp,ta*
0B7BS
D$ #70872010
%$ #70#72010
Job Don),rmF$ 132081270