Sir William Osler, the father of modern medicine, said “the desire to take medicine is perhaps the greatest feature that separates man from animal.” Determination of the benefit of a medication can be challenging and includes a number of factors, such as pharmacologic activities on the disease pathophysiology, pharmacokinetic properties and patient characteristics.1,2 An additional,…
Immune checkpoint inhibitors (ICIs) are at the forefront of advances in cancer therapy and have shown promising results for progression-free survival. Checkpoint signaling pathways, such as cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1), normally regulate the immune response to promote self-tolerance and prevent tissue damage and inflammation. PD-1 is a…
A 36-year-old woman presented at the Johns Hopkins Arthritis Center for a second opinion regarding a diagnosis of psoriatic arthritis (PsA). One year prior to our evaluation, she had developed pain and stiffness in her hands, feet, knees, ankles, elbows and shoulders. She had mild plaque psoriasis of the scalp and base of the neck,…
Take the challenge. CPT codes: 99203/99243 ICD-10: M25.521, M25.522, M25.561, M25.562 History—Comprehensive: The history of present illness is extended, the review of systems is complete, and the past medical, family and social history are documented. All three of the HPI, ROS and PFSH are needed to achieve the history level as comprehensive. Examination—Detailed: This level…
A 55-year-old female patient with pain in multiple joints is referred to the office by her primary care physician. She complains of pain in both knees and both shoulders. She rates the pain at 7 on the pain scale. Her pain is worse at night after she gets off work. Soaking in her hot tub…
Take the challenge. Scenario 1 is the correct answer. Although documentation of both scenarios supports a Level 4 visit, only one supports the medical necessity to code an evaluation and management (E/M) visit on the same day with a procedure. Scenario 1 supports the need for a separate E/M visit, because a new problem was…
Rheumatologists and orthopedic surgeons must frequently collaborate to provide optimal patient care. Sometimes, they may even work at the same practice and form a care team for easy collaboration. Still, patient management from both specialties can be challenging, and specialists from both sides can learn from each other. How Crossover Starts Rheumatologists and orthopedic surgeons…
Based on the classification system developed by the Chapel Hill Consensus Conference, anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis is defined as a necrotizing vasculitis involving small vessels that is associated with myeloperoxidase (MPO) ANCA or proteinase 3 (PR3) ANCA and displays minimal immune deposits. The mechanism behind the pathogenesis of ANCA-associated vasculitis is not fully…
Antiphospholipid syndrome (APS) is an autoimmune clotting disorder that may present catastrophically with multiple thromboses over a short period of time. In this article, we examine the case of a woman with undiagnosed APS whose first symptoms presented during a long-haul flight. A review of the literature on thrombosis at high altitudes and during long…
As Lyme disease and Lyme arthritis spread to new regions in North America, physicians may ned to become aware of their signs and symptoms. Allen C. Steere, MD, says “Lyme arthritis is more complicated to treat than other manifestations of the disease.” Here are some best practices for treating Lyme arthritis…