RA Visit with a Separate Identifiable Service
A 63-year-old obese female Medicare patient with rheumatoid arthritis (RA) returns to the office for a follow-up visit. She is currently 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 for her left knee, which has been very swollen and stiff for the past two weeks. She denied fevers, but reports that she has had epigastric pain every day for the past three weeks, which has progressively worsened, but has shown improvement with the use of 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 shows regular rate and rhythm with no murmurs or friction rubs. The abdomen is soft with epigastric tenderness on palpation and has no masses or hepatosplenomegaly. The musculoskeletal exam finds: bony proliferation and slight ulnar deviation in bilateral wrists; bony proliferation and slight decreased flexion in bilateral second through fifth proximal interphalangeal joints; bony proliferation and crepitus in right knee; and irritability, 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: Magnetic resonance imaging (MRI) of the knee without contrast was performed to determine the level of joint damage of the left knee. After discussion of therapeutic options with the patient, arthrocentesis and intraarticular corticosteroid injections were performed on both knees with ultrasound guidance. Guidance was performed due to the patient’s body-mass index of 44; there has 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 also given a prescription for a proton-pump inhibitor for the gastritis. Complete blood count and liver function tests were ordered.
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