SUBJECTIVE: The patient is here complaining of a (1)________ of her arthritic pain. She gets arthritic pain in her knees, ankle, back, and spine. She has a problem taking (2)________ secondary to GI upset. The patient has a history of rheumatoid arthritis, fibromyalgia, (3)________, and osteoarthritis. She is currently on Plaquenil. She had to self-discontinue her (4)________ secondary to GI
upset. She also takes a Bayer aspirin each day. This is a longstanding problem, and the patient has no new acute changes.
OBJECTIVE: HEENT unremarkable. (5)________ Regular rate and rhythm without murmur. Lungs CTA. Extremities: No (6)________ edema. Musculoskeletal: No joint (7)________ or edema. There are no rheumatoid (8)________ noted.
ASSESSMENT/PLAN:
1. Rheumatoid arthritis, with (9)_______ pain. Patient is to continue with her Plaquenil. Will give trial of Arthrotec 50 mg daily to t.i.d. as her GI tract tolerates, #100, refill #1 prescription given.
2. Plaquenil use. Will check CBC and CMP today. Will also check (10)________, TSH, and lipid panel, as these are required at this time.
1. flare
2. NSAIDs
3. osteoporosis
4. naproxen
5. Cor:
6. peripheral
7. erythema
8. nodules
9. musculoskeletal
10. ESR
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