X-rays on 6/19/08 included films of the hands and wrists, which showed some mild osteoarthritic changes in the DIP and PIP joints. There was minimal narrowing in several of the MCP joints. The intercarpal joints were intact. No definite erosions were seen in the MCP or wrist areas.
X-rays of the left elbow were normal with minimal osteoarthritic change noted. X-rays of the feet and ankles showed mild osteoarthritic changes in the first MTP joints. There was minimal calcification at the right Achilles tendon insertion. Both ankles were intact with minimal osteoarthritic changes seen in each ankle.
X-rays of the left shoulder showed the articular surfaces to be intact with no significant narrowing of the joint space. Mild osteoarthritic change was seen in the glenoid fossa, and minimal osteophytic lipping was seen under the humeral head. Mild osteoarthritic change was seen in the acromioclavicular joint.
X-rays of the lower back and right hip showed some minimal degenerative disc change at LS-S1. The right sacroiliac joint showed changes of mild to moderate sacroiliitis. The left sacroiliac joint was unremarkable. The right hip had mild eccentric narrowing of the joint space with moderate osteoarthritic change in the acetabular roof and superior acetabular rim and to a lesser extent the inferior aspect of the acetabulum.
X-rays of the knees weight bearing showed the articular surfaces to be intact. There was minimal bicompartmental narrowing of the right knee, a bit more medially than laterally, and some minimal bicompartmental narrowing of the left knee, a bit more laterally than medially. Mild osteoarthritic changes were seen in both knees, primarily in the medial compartment areas.
A computer-quantitated bone and joint scan was done on 6/23/08. This showed arthritic activity in both sacroiliac joints as well as the sacrum. Some mild arthritic contour changes were seen in the neck at C3 and C4. There was diffuse arthritic activity in both shoulders, more on the left than on the right. Both sternoclavicular joints showed some increased activity, as did the manubrium. There was diffuse increased arthritic activity in the right hip, especially in the acetabular portion. Both knees showed some slightly increased arthritic activity. in the medial compartments.
Laboratory studies on 6/19/08 included an SMA chemistry profile, which showed a very mild elevation of the nonfasting glucose at 115 mg/dL but was otherwise normal. The BUN was 19 with creatinine 0.8. Electrolytes, calcium, and liver and muscle enzymes were all normal. Testing for lupus anticoagulant was negative. The uric acid was normal. Hepatitis 8 surface antigen and hepatitis C antibody tests were negative or normal. The serum and urine protein immunoelectrophoretic patterns were normal. The TSH thyroid was normal. The B12 was normal. The RPR was nonreactive. Rheumatoid factor was negative. The C-reactive protein was normal. The ANA was very weakly positive at 1:40, speckled, and is not felt to be clinically significant. Complement studies were normal. Cryoglobulins were negative. SSA and SSB, Sm, and RNP antibodies were negative. PANCA and cANCA antibodies were negative. Scl-70 antibodies were negative. Thyroid antibodies were negative. Anticardiolipin antibodies were negative. HLA-B27 was nol present. The 25-0H vitamin D level was normal. The serum ACE was normal. CCP IgG antibodies were negative. Anti-double-stranded DNA antibodies were negative. The sedimentation rate was normal at 5 mm/hr Westergren. The urinalysis was normal. The CBC showed some very minimal anemia with hematocrit 36.5% and hemoglobin 12.5 g. WBC was normal at 7.3. Platelets were normal at 288,000.
IMPRESSIONS: I think that Mrs. Kienast has one of the seronegative rheumatoid varianl types of arthritis with features of undifferentiated spondyloarthropathy, lumbar type. She has an inflammatory type uptake on her bone and joint scan in multiple areas, and she has severe osteoarthritic involvement of the right hip. (She is going to need to have a right hip replacement one of these days, probably in the fairly near future.) She has had some fatigue and mild Raynaud’s phenomenon and some very mild Sjogren’s type symptoms. She has had a lot of problems with gastritis and reflux. She has some very minimal anemia. She also has hypertension for which she is on treatment.
RECOMMENDATIONS: I think methotrexate might offer her the best opportunity to slow her arthritis down at bit. If methotrexate is not adequate, then some of the biologic type drugs such as Humira, Enbrel, or Remicade might be considered. I do not think any of these drugs are going to salvage her right hip. I gave her some written and verbal information about methotrexate and side effects related to it. She knows it can adversely affect her liver, lungs, and blood. She needs to avoid alcoholic beverages and to avoid sulfa type drugs such as Bactrim or Septra while on methotrexate. We check patients about every eight weeks on methotrexate also and monitor the CBC and liver tests, etc. She wants to go ahead and try methotrexate. Today, I gave her a prescription for methotrexate 2.5 mg x 7 tablets all at once, one time weekly. I put her on folic acid 1 mg tablets, 2 tablets daily or as directed, to cut down on side effects due to methotrexate. She is going to continue on the Mobic 15 mg daily. I gave her some Protonix to take 40 mg once or twice daily to hopefully help protect her stomach from the Mobic. I gave her a pneumococcal pneumonia vaccination today. She needs to get that every five years. She needs to get her flu shot every fall. I gave her some Lortab 10 mg to take % or 1 q 6 h sparingly p.r.n. for pain. She knows that the hydrocodone can be addicting, and we went over that with her also. If all goes well, I would like to see her again in the office in about eight weeks for followup on methotrexate or call p.r.n. if any problems. She is going to follow up with Dr. Tucker about her right hip problem.