Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Rheumatoid Arthritis - Consult
Description: A 71-year-old female who I am seeing for the first time. She has a history of rheumatoid arthritis for the last 6 years. She is not on DMARD, but as she recently had a surgery followed by a probable infection.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: A 71-year-old female who I am seeing for the first time. She has a history of rheumatoid arthritis for the last 6 years. She was followed by another rheumatologist. She says she has been off and on, on prednisone and Arava. The rheumatologist, as per the patient, would not want her to be on a long-term medicine, so he would give her prednisone and then switch to Arava and then switch her back to prednisone. She says she had been on prednisone for the last 6 to 9 months. She is on 5 mg a day. She recently had a left BKA and there was a question of infection, so it had to be debrided. I was consulted to see if her prednisone is to be continued. The patient denies any joint pains at the present time. She says when this started she had significant joint pains and was unable to walk. She had pain in the hands and feet. Currently, she has no pain in any of her joints.
REVIEW OF SYSTEMS: Denies photosensitivity, oral or nasal ulcer, seizure, psychosis, and skin rashes.
PAST MEDICAL HISTORY: Significant for hypertension, peripheral vascular disease, and left BKA.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Denies tobacco, alcohol or illicit drugs.
VITAL SIGNS: BP 130/70, heart rate 80, and respiratory rate 14.
HEENT: EOMI. PERRLA.
NECK: Supple. No JVD. No lymphadenopathy.
CHEST: Clear to auscultation.
HEART: S1 and S2. No S3, no murmurs.
ABDOMEN: Soft and nontender. No organomegaly.
EXTREMITIES: No edema.
ARTICULAR: She has swelling of bilateral wrists, but no significant tenderness.
LABORATORY DATA: Labs in chart was reviewed.
ASSESSMENT AND PLAN: A 71-year-old female with a history of rheumatoid arthritis, on longstanding prednisone. She is not on DMARD, but as she recently had a surgery followed by a probable infection, I will hold off on that. As she has no pain, I have decreased the prednisone to 2.5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow. If in a couple of weeks her symptoms stay the same, then I would discontinue the prednisone. I would defer that to Dr. X. If she flares up at that point, prednisone may have to be restarted with a DMARD, so that eventually she could stay off the prednisone. I discussed this at length with the patient and she is in full agreement with the plan. I explained to her that if she is to be discharged, if she wishes, she could follow up with me in clinic or if she goes back to Victoria, then see her rheumatologist over there.
Keywords: consult - history and phy., prednisone, joint pains, rheumatoid arthritis, arthritis, dmard, rheumatologist, rheumatoid, pains,