A 53-year-old obese female Medicare patient with rheumatoid arthritis returns to the office for a follow-up visit. She currently resides in a skilled nursing facility. She is on sulindac, methotrexate, and folic acid. The patient’s methotrexate dose was increased at her last visit two months ago. She reports that her arthritis is doing well, except in her left knee, which has been very swollen and stiff for the past two weeks. She denies fever and reports that she experiencing epigastric pain for the past three weeks. The pain has progressively worsened and occurs every day, but improves with Mylanta. Her appetite is unchanged and she denies vomiting, diarrhea, or hematochezia. She states that she does not have any chest pain, dyspnea, or other complaints.
On exam, the patient is alert and oriented. There is no lymphadenopathy. Her lungs are clear. Her heart has regular rate and rhythm with no murmurs or friction rubs. The abdomen is soft with epigastric tenderness on palpation. She has no masses or hepatosplenomegaly.
On musculoskeletal exam, there is bony proliferation and slight ulnar deviation in bilateral wrists and bony proliferation and slight decreased flexion in bilateral second through fifth proximal interphalangeal joints. There is bony proliferation and crepitus in the right knee and irritability, a large effusion, warmth, and decreased flexion in left knee without erythema. She does have some scar tissue from a past knee surgery. All other joints are unremarkable with full range of motion.
Diagnoses:
- Rheumatoid arthritis with knee effusions
- Nonsteroidal antiinflammatory drug-induced gastritis
Plan: After discussion of therapeutic options with patient, arthrocentesis and intraarticular corticosteroid injections are performed on both knees with ultrasound guidance. Guidance was performed due to the patient’s BMI of 44; there had been difficulty positioning the needle for the procedure. The patient was changed from sulindac to celecoxib and will continue on methotrexate and folic acid. She was given a prescription for a proton-pump inhibitor for the gastritis. A complete blood count and liver function tests were ordered.
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