PROBLEMS:
1. Psoriatic arthritis characterized by psoriatic skin lesions as well as bilateral wrist pain and inflammation, maintained on methotrexate.
2. Coronary artery disease, status post myocardial infarction with stent, status post stenting in the fall.
SUBJECTIVE: The patient is a very pleasant (XX)-year-old male, who returns today for routinely scheduled appointment. He is accompanied today by his wife. He reports that since his last visit, he has been doing relatively well with respect to psoriatic arthritis. His main symptom involves wrist inflammation that really has not been a problem. He did not have morning stiffness. He does have low back pain, usually worse at night. He does not have any flares. He has been having bilateral shoulder pain as well as right buttock/outer hip pain. These have been chronic issues.
He has had multiple cortisone injections in his shoulders by another physician, and he was told that they wanted to remove some bone spurs in his shoulders. He is electing to just continue to manage conservatively and not proceed with surgery. In terms of his skin, he has a little bit of psoriasis in his scalp, but otherwise is fine. He overall feels that if he can maintain his current state of things, he would be very happy.
CURRENT MEDICATIONS: Methotrexate 20 mg p.o. q. week, leucovorin 5 mg p.o. q. week, alendronate 70 mg p.o. q. week, calcium with vitamin D, folic acid 2 mg daily, Plavix, Crestor, metoprolol, aspirin, fish oil, lorazepam, zolpidem, and pantoprazole.
OBJECTIVE: Vital Signs: Blood pressure 116/68, pulse 52, weight 198 pounds, temperature 97.2, and 98% on room air. Pain is 0/10. General: No acute distress, alert and oriented x3. HEENT: Sclerae anicteric. No conjunctival irritation. Oral mucosa is moist. No oral ulcers. Neck: Supple. No lymphadenopathy. Lungs: Clear to auscultation bilaterally. Musculoskeletal: The patient had full range of motion of all of his joints with no joint tenderness. He has no subacromial bursal tenderness. He has no greater trochanteric tenderness. He did have tenderness posterior to the greater trochanter, on the right side, more in the buttocks area in the upper outer quadrant.
ASSESSMENT AND PLAN:
1. Psoriatic arthritis. The patient is doing well. We will continue his current regimen of 20 mg of methotrexate. Refill of this, leucovorin, folic acid and Fosamax were all sent to his pharmacy today.
2. History of osteopenia. The patient will continue on Fosamax, calcium with vitamin D. We will let him know what the bone density test shows once we get the report.
3. Return visit in six months.
SUBJECTIVE: The patient is seropositive RA. Pain scale was 0/10, so she is feeling well. She had a flare, which was treated with some low-dose corticosteroids, and she has been maintained on 2.5 mg since then with no significant a.m. or p.m. stiffness and is able to do all of her vocational and leisure activities. No infectious complications or oral ulcers or hair thinning. No fevers, chest pain, or shortness of breath. No cough, wheezing, abdominal pain, nausea, vomiting, or diarrhea. She had x-rays four months ago, which showed periarticular osteopenia but no erosions.
MEDICATIONS: Methotrexate 20 mg weekly, leucovorin 5 mg 12 hours after the methotrexate, daily folic acid and 2.5 mg of prednisone, as well as calcium, vitamin D, but she was able to tolerate from a GI side effect profile.
OBJECTIVE: Her blood pressure is 126/78, heart rate 78, weight 160 pounds, temperature 97.2, and 100% on room air. Pain scale is 0/10. She has full range of motion of all joints; neck, shoulders, elbows, wrists, knees, and ankles. She is slightly full over the second MTP at the left hand without any tenderness. Good hand grip bilaterally. Knees are cool without effusion, nontender over any of the toes, and she is wearing high heels at today’s visit.
ASSESSMENT AND PLAN: Seropositive rheumatoid arthritis, doing fairly well on 2.5 mg of prednisone and 20 mg of methotrexate. We are going to ask her to change her prednisone to every other day to try to drop her average dose to something less than 2 mg, and she will get her monitoring labs done next week and follow up with us in two months. She will see us sooner if she develops a flare.
