Henry Ford Case Study

MEDICATIONS:

1.  Methotrexate (start date January 2008) 10 mg weekly.

2.  Folic acid 1 mg a day.

3.  Acetaminophen.

CHIEF COMPLAINT:  Joint pain.

HISTORY OF PRESENT ILLNESS:  Patient has joint pain.  She felt better when she was taking sulindac.  She claims this was stopped by her primary care physician.  She has morning stiffness for about an hour.  Partial relief with the use of acetaminophen.  Patient appears to be taking methotrexate sporadically.

REVIEW OF SYSTEMS:  No weight loss.  No cough or shortness of breath.  No abdominal pain.  No swelling in the legs.

PAST SURGICAL HISTORY:  Patient was seen by Dr. Lane Scheiber, who is a rheumatologist in the downriver area.  He prescribed sulindac, use of which provided her with modest relief of joint pain.

SOCIAL HISTORY:  Patient’s husband died with carcinomatosis on 15th of May of this year.

EXAMINATION:

VITAL SIGNS:  Weight is 122 pounds (133 pounds in January 2008), blood pressure 133/85 with a pulse of 81, temperature 97.5.

MUSC/SK:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion, and deformity was performed was performed today.  I found swelling in the PIPs, MCPs, and wrists of both hands today.  Knees were warm to touch, but there were no anterior effusions.  No nodules at the elbows.  Joint count swelling today was 17 and joint count tender is 0.

IMPRESSION:  Rheumatoid arthritis in flare.

MEDICAL DECISION MAKING:  Methotrexate 2.5 mg prescribed to be taken as 3 tablets twice a day on Mondays, and sulindac 200 mg to be taken twice a day.  Laboratory tests were requested today.  Return in 8 weeks.