A 54-year-old female with rheumatoid arthritis (RA) and osteoporosis (OP) returns to the rheumatology practice for a follow-up visit. She reports that the pain in her hands and feet is slightly worse than last visit. She has morning stiffness for one hour with increased fatigue and swelling in her fingers. She continues to have dry eyes and mouth. She denies fever, chills, cough, and shortness of breath, and she has no rashes.
She denies any night vision cueing. She’s 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, Plaquenil, Fosamax, folic acid, calcium, and vitamin D.
The physical examination reveals a well female in no apparent distress. Her vital signs are a blood pressure of 140/ 90, a pulse of 88, a temperature of 98.6° F, a weight of 150 pounds, and a 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 the metacarpohalangeal joints bilateral and all metatarsophalangeal joints. There are no deformities. She has a flat affect.
Assessment
- RA, worse on chronic medicine
- OP, stable on chronic medicine
- Elevated blood pressure, new problem
Plan
- Start a tumor necrosis factor inhibitor. A skin test and chest X-ray was ordered for a tuberculosis screen. Labs were ordered for disease evaluation and medication monitoring. She is to continue other medicines. The physician held a lengthy discussion with patient concerning risks and benefits.
- An OP dual-energy X-ray absorptiometry was due and ordered to re-assess. The patient was asked to continue Fosamax, calcium, and vitamin D.
- The patient was asked to check her blood pressure at home and keep a log of its results.
- Labs were ordered to check toxicity level of drugs. A complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, C-reactive protein, and hepatitis panel were ordered due to disease and medicines.
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Case by Melesia Tillman, CPC, CRHC, CHA, coding specialist for the ACR.
