In the beginning of April, the pt started noticing her hands were hurting. By the end of April, it was in her ankles, then her knee, now her hips. Doctor thinks it is arthritis due to vax. Per doc 197786, patient continues to have arthritic pain in numerous joints.   The follow up received on 10/4/00 states, "I saw pt today in follow up and she continues to have a lot of discomfort in that knee. She finds that whenever she tries to exercise that it causes her problems and particularly keeps her awake at night. She is not currently taking any medications. In my previous letter to you I believe I enclosed a copy of her MRI which shows a partial tear in the posterior cruciate ligament but I do not believe it is anything that would be repaired at this time, though if the problem persists we may want her to see an orthopedic surgeon. There were significant degenerative changes present within the knee and the meniscus as a cause for her complaints. At this point I decided to try her on a NSAID to see if we can settle things down and chose Arthrotec 75mg bid with food. I will see her back in three weeks time." "I saw pt today in consultation. She is a pleasant 47 y/o lady who states that in March of this year she had her third injection of the Lyme vaccine. About 2 or 3 weeks alter hse began noticing for the very first time discomfort and some pain in the PIP joints of her fingers and subsequently pain and discomfort in the left knee. In fact it even feels swollen on occasion but is is the left knee that bothers her by far more than anything else. She has had some discomfort in her ankles and hips, but it is mostly the knee and PIP jints that have been giving her problem. She was seen by yourself and bloodwork was within normal limit, with the exception of her Lyme titer which did come up positive, but this was probably due to the vaccine. Her eSR, RA factor, and ANA were normal. She was started on Celebrex which she did not feel helped her much. She was then placed on Vioxx which did help a lot but also caused gastric upset. She does give a long standing history of ulcers and gastritis that has gone on for many years. She denies any skin rash, conjunctivitis, urethritis, or Raynaud's syndrome and hasbeen in otherwise good health. Her examination today revealed a well developed, well nourished lady in no acute distress. HEEN and T were within normal limits. Her lungs were clear, her heart was regular, and her abdominal exam was negative. Her upper extremities were completely within normal limits with the exception of the PIP joints of all her fingers. They seemed to be somewhat thickened and mildly tender. The lower extremities revealed good range of motion of her hips and knees without any swelling. The left knee though does have pain on compression of the patella and also tenderness over the lateral joint space on compression of that area. There was good range of motion. There did not appear to be any crepitus. Her ankles and toes were within normal limits. Her lower back and cervical spine moved well. This lady appears to be developing what I feel is some osteoarthritis in her hands and probably some mechanical derangement in the left knee, either consistent with a torn meniscus or possibly dhondromalacia of the patella. I did suggest that she needs to wear good shoes all the time and when she comes home at night she can no longer run around barefoot. I have elected not to start her on any medication, in view of her problem with her stomach, but have recommended that we get an MRI of the knee ot see if we can pinpoint just what is going on at that level. I will see her back once that test is obtained."