Subjective Chief Complaint: “I have pain in all of my joints, a swollen left knee, and stiffness every morning.” HPI: Janet Hobbs is a 58-year-old woman who presents to her rheumatologist with generalized arthralgias, a swollen left knee, and morning stiffness. These symptoms have been occurring with increasing severity for the past several weeks. She presented with similar symptoms 3 months ago, at which time her drug regimen was changed from methotrexate and NSAID therapy to her current regimen below. PMH: RA × 6 years S/P, hysterectomy 4 years ago, HTN × 10 years FH: Father died from complications after a traumatic fall at age 65. Mother died of a hip fracture and pneumonia at age 78. No siblings. SH: Housewife; married for 32 years; has two grown children with no known medical problems. Denies alcohol or tobacco use. Volunteers in the community extensively, but has been doing less in the past 2 months. Meds: Hydrochlorothiazide 25 mg PO Q AM, Norvasc 10 mg PO once daily, Nabumetone 750 mg = 2 tabs po Q HS, Prednisone 5 mg = 1/2 tab po Q AM, Methotrexate 2.5 mg = 6 tabs po once a week, Hydroxychloroquine 200 mg = 1 tab po BID, Sulfasalazine EC 500 mg = 1 tab po BID, Folic acid 1 mg PO once daily. The patient receives medications at a local community pharmacy. The medication profile indicates that she refills her medications on time on the first of each month. All: Penicillin (rash 25 years ago) ROS: Swelling in the left knee; decreased ROM in hands; morning stiffness every day for about 3 hours; fatigue experienced daily during afternoon hours; denies HA, chest pain, SOB, bleeding episodes, or syncopal attacks; denies nausea, vomiting, diarrhea, loss of appetite or weight loss; reports minor visual changes corrected with stronger prescription glasses. Kindly answer patient therapeutic care plan. TYSM
Subjective
Chief Complaint: “I have pain in all of my joints, a swollen left knee, and stiffness every morning.”
HPI: Janet Hobbs is a 58-year-old woman who presents to her rheumatologist with generalized arthralgias, a swollen left knee, and morning stiffness. These symptoms have been occurring with increasing severity for the past several weeks. She presented with similar symptoms 3 months ago, at which time her drug regimen was changed from methotrexate and NSAID therapy to her current regimen below.
PMH: RA × 6 years S/P, hysterectomy 4 years ago, HTN × 10 years
FH: Father died from complications after a traumatic fall at age 65. Mother died of a hip fracture and pneumonia at age 78. No siblings.
SH: Housewife; married for 32 years; has two grown children with no known medical problems. Denies alcohol or tobacco use. Volunteers in the community extensively, but has been doing less in the past 2 months.
Meds: Hydrochlorothiazide 25 mg PO Q AM, Norvasc 10 mg PO once daily, Nabumetone 750 mg = 2 tabs po Q HS, Prednisone 5 mg = 1/2 tab po Q AM, Methotrexate 2.5 mg = 6 tabs po once a week, Hydroxychloroquine 200 mg = 1 tab po BID, Sulfasalazine EC 500 mg = 1 tab po BID, Folic acid 1 mg PO once daily. The patient receives medications at a local community pharmacy. The medication profile indicates that she refills her medications on time on the first of each month.
All: Penicillin (rash 25 years ago)
ROS: Swelling in the left knee; decreased ROM in hands; morning stiffness every day for about 3 hours; fatigue
experienced daily during afternoon hours; denies HA, chest pain, SOB, bleeding episodes, or syncopal attacks; denies nausea, vomiting, diarrhea, loss of appetite or weight loss; reports minor visual changes corrected with stronger prescription glasses.
Kindly answer patient therapeutic care plan. TYSM
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