HF Henry Ford Case study

MEDICATIONS:

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

2.  Folic acid 1 mg a day.

3.  Prilosec 20 mg a day.

4.  Diclofenac sodium gel applied topically to the knee.

5.  Patient is receiving prednisone 10 mg today.

CHIEF COMPLAINT:  “I feel better.”

HISTORY OF PRESENT ILLNESS:  Patient has reduction in morning stiffness.  Joint pain has improved.  Patient has stiffness from time to time and would like to take something for it.  She was advised to stop taking Naprosyn because of stomach upset.  Stomach symptoms have improved with the use of Prilosec.

REVIEW OF SYSTEMS:  No weight loss.  No abdominal pain.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Weight is 151 pounds, blood pressure 139/78 with a pulse of 88, temperature 97.0.

MUSC/SK:  A complete peripheral joint evaluation for swelling, tenderness on palpation, limitation of motion, and deformity was performed today.  The results compared to the examination documented on the articular examination sheet on March 31, 2008.  In the right hand, there was swelling and tenderness on palpation of the right thumb MCP and tenderness on palpation of the third PIP.  In the left hand, there was swelling and tenderness of the left wrist.  There were nodules palpable along the olecranon process of both elbows but no swelling.  In the lower extremity, the knees were warm to touch but there was no tenderness on palpation.  No anterior effusions.  There is limitation of motion of both ankles.  No squeeze metatarsal phalangeal joint tenderness.  Joint count swollen and tender today was 2 and 3 respectively.  This is in contrast to a joint count swelling and tender of 11 each in March of this year.

Laboratory test results reveal evidence of methotrexate toxicity.

IMPRESSION:

1.  Rheumatoid arthritis with monthly use of methotrexate and prednisone.

MEDICAL DECISION MAKING:  Patient will continue with the current anti-rheumatic regimen.  She reports feeling better when she takes enteric-coated aspirin.  While she is taking Prilosec, I think she could use the aspirin as needed.  Return in 8 weeks.  Prescriptions provided for methotrexate.