Scenario 1
History: A 45-year-old male patient with sero-negative rheumatoid arthritis affecting multiple sites, but with no organ or systems involvement, comes for a follow-up visit. The patient reports swelling of the left knee with throbbing left knee pain. He rates the severity of his pain at an 8 on a 10-point scale. The pain started four weeks ago and has gradually worsened. He took over-the-counter NSAIDs (non-steroidal anti-inflammatory drugs) to relieve the pain with no success. He reports no weight change, dyspnea, skin rashes, other musculoskeletal pains or chest pain. The patient is currently on methotrexate 20 mg by mouth weekly. He had surgery to remove his gallbladder one year ago. He has no family history of rheumatic disease.
Exam: The patient’s weight is 295 lbs., temperature is 98.9ºF, and his blood pressure is 115/80. The HEENT (head, ears, eyes, nose and throat) exams show the pupils are round and sclerae clear, no mouth ulcers and no hearing loss. His heart rate is within normal limits and his heart sounds are normal. His abdomen is not distended or tender. His lungs are clear to auscultation. Except for the left knee, the musculoskeletal exam is normal. The left knee is swollen and tender to the touch but not warm. He has pain in the left knee. His knee lacks 5 degrees of full extension, and the range of motion is only 45 degrees. His gait is unstable, with a tilt to the left side when walking across the room.
Assessment & Plan: The patient is in a lot of pain, and after discussing options with the patient, it is decided to perform a knee joint injection. After obtaining prior authorization, xylocaine is injected to numb the area; 40 mg of methylprednisolone acetate is then injected into the left knee. An X-ray of the left knee is ordered to confirm the diagnosis of secondary osteoarthritis. Because the patient is obese, the injection is done via ultrasound guidance, and a permanent recording of the guidance is entered in the patient’s medical record.
No changes are made to the patient’s methotrexate dosage, but 50 mg of tramadol three times a day as needed is prescribed for pain. He is advised to continue taking methotrexate and to schedule a follow-up visit in three weeks.
Scenario 2
History: A 55-year-old woman with rheumatoid arthritis without rheumatoid factor and with secondary osteoarthritis of the left knee returns to the office for her scheduled injection of Synvisc One in her left knee. She was last seen in the office two weeks before. She reports pain that lasts approximately 30 minutes in the mornings, along with swelling in her knee. She rates her pain at a 6 on a 10-point scale. She denies any fever, shortness of breath, skin rashes, mouth sores or weight change.
