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Outpatient Consultation Patient Case Number: OPC120-Gile…
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Outpаtient Cоnsultаtiоn Pаtient Case Number: OPC120-Giles, Rоderick Patient Name: Roderick Giles DOB: 11-04-65 Sex: M Date of Service: 08-11-XX Physician: Samuel Stiles, MD Chief Complaint: Bilateral hand pain History of Present Illness: I am seeing Mr. Giles at the request of Dr. Stiles who was last seen in the office about 3 months ago. He is a pleasant 53 y/o man with a history of RA and is currently on Humira and Sulfasalazine. He was also on MTX but was stopped because of lung problems. He also has lung lesions that are being followed by pulmonary. He was cleared to restart Humira after his hospitalization. He does not believe that his Humira is working for him. He has been on Humira for some time, and does not believe he has had any benefit. He is due for his TB test. He would like to discuss switching medications. He rates his pain as an 8/10, and has morning stiffness for about 4 hours each morning. Past Medical History: RA, DDD (lumbar) Family History: noncontributory Social History: no smoking; no alcohol use. Medications: Humira, Sulfasalazine, Prednisone, Ibuprofen Allergy: Augmentin, Penicillin. Review of Systems: Constitutional: Denies fatigue, unintentional weight loss, fever, chills HEENT: Denies headache, dizziness, sore throat Cardio: Denies chest pain, palpitations Lungs: Denies SOB, cough Gastrointestinal: Denies nausea, abdominal pain, diarrhea Genitourinary: Denies hematuria, dysuria Skin: No rashes Heme: No bruising. Neuro: No paresthesia Psych: Negative Vitals: Temperature 98.6°F Pulse 68 Respirations 20 Blood Pressure 125/60 Height 6’0ft Weight 200lbs BMI 27.1 Physical Examination: Head: normocephalic. ENT: No signs of acute inflammation. Neck: Supple, no LAD Heart: RRR without murmur click or rub. No ectopics appreciated. Lungs: CTA. Abdomen: Soft non-tender, without organomegaly. Extremities: No rash or significant peripheral edema. Distal neurovascular exam is intact without cyanosis or clubbing. Musculoskeletal: Axial Skeleton: Cervical spine has no tenderness to palpation Peripheral Musculoskeletal: Tenderness and synovitis of MCPS 2, 3 ,4 bilaterally. Neuro: Non-focal. Psych: Normal affect and mood. Impression: RA involving both hands DDD of lumbar spine Plan: Patient presents to clinic today for RA. At this time, he does not believe Humira has helped him at all. He would like to consider other options. Discussed Enbrel, Actemra, and Xeljanz with him. He would like to try Enbrel. Discussed dosing, side effects, and also monitoring with him. He will continue on Sulfasalazine. He is due for his TB test, and this will be done today. He will have his wash out period of Humira that will end in a couple weeks, and he can start Enbrel after that. Will give him prednisone 5mg daily during the wash out period. Discussed exercise and pool aerobics. Total time spent with patient more than 60 minutes. Electronically Signed By: Samuel Stiles, MD Copyright © 2020 by The American Health Information Management Association. All Rights Reserved. [BLANK-1] [BLANK-2] [BLANK-3]
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