A 54-year-old female with rheumatoid arthritis (RA) is seen by the rheumatologist for a follow-up visit. She reports that the pain in her hands and feet is slightly worse than at her last visit. She has amorning stiffness for one hour with swelling in her fingers, and increased fatigue. She continues to have dry eyes and mouth, but denies fever, chills, cough, and shortness of breath. She has no rashes.
The patient denies any night-vision cueing and has had no falls or fractures. Her past medical history was reviewed with no additions and no new surgeries. She has no known allergies. There was no change to family or social history since January of this year. Her current medications include methotrexate, low-dose prednisone, and plaquenil.
The physical examination revealed a well female in no apparent distress. Her vital signs show a blood pressure of 140/90, pulse of 88 BPM, temperature of 98.6°F, weight of 150 lbs., and height of 5’6”. A head, eyes, ears, nose, and throat exam is within normal limits, except for dry mucous membranes. Her neck is within normal limits. Her cardiovascular and lung exam are normal. Her abdomen and skin are normal. A complete joint exam shows swelling of bilateral metacarpohalangeal joints and all metatarsophalangeal joints. There are no deformities. Her psych is flat affect.
Assessment:
- RA: Worse on chronic medicine
- Elevated blood pressure: New problem
Plan:
- Start tumor necrosis factor (TNF) inhibitor. Physician discussed the risk and benefits of TNF with patient at length. A skin test and chest X-ray were performed for tuberculosis screening. Labs were drawn for disease evaluation and medication monitoring. Patient is to continue other medicines. A reminder of the risks and benefits of current medications were reviewed with patient.
- Blood pressure: Patient to check at home and keep a log.
- Labs were ordered to check toxicity level of drugs. Complete blood count, erythrocyte sedimentation rate, C-reactive protein, and hepatitis panel were ordered due to continuation of current medication
How should this visit be coded?
