Age: 62.0
Sex: F
Vaccine: COVID19
Symptoms: Raynaud's phenomenon, Red blood cell count normal, Red blood cell sedimentation rate increased, Red cell distribution width increased, Swelling face
Clinical narrative: MD at 06/14/21 0835 Follow-Up Video Visit Progress Note Video Visit Consent: The patient has given verbal or written consent for delivery of health care, via telehealth through a Video Visit appointment. Patient was using real-time Telehealth tools between my location and the patient's location. Prior to discussing medical issues, the patient provided informed verbal consent to perform this consultation using Telehealth tools, and all questions about the Telehealth interaction were answered.  Patient confirms they are located in a safe location and within the state:  Yes Patient states location at time of video visit. Patient confirmed date of birth and the phone number where they can be reached in case video visit is disconnected.    In accordance with federal, state, and institutional recommendations to reduce person-to-person contact during the ongoing outbreak of Coronavirus, a scheduled in-person clinic visit was reformatted to a telehealth consultation.       ASSESSMENT AND PLAN: 1. Giant cell arteritis (CMS/HCC) 2. Raynaud's phenomenon without gangrene 3. Anti-RNP antibodies present follow-up visit for giant cell arteritis with extracranial involvement with pain in extremities especially right arm, arteritis/vasculitis on CT angio, elevated markers of inflammation diagnosed 05/2021, symptoms started 2 weeks after 2nd dose of COVID vaccination Raynaud's phenomena, weakly positive RNP antibody currently on prednisone 40 mg daily, Actemra 162 mg subcutaneous injection once a week. Doing better on current treatment. No active inflammatory arthritis appreciated. No signs or symptoms for active vasculitis. Reviewed results of the blood work with normalization of markers of inflammation, improvement in thrombocytosis, rest of the blood counts look okay. Discussed potential treatment options with the patient and plan to repeat markers of inflammation later this week and lower the dosage of prednisone to 30 mg daily for 2 weeks, then 20 mg daily. - Comprehensive blood work as listed below -based on results, lower the dosage of prednisone to 30 mg daily for 2 weeks, then 20 mg daily -continue with Actemra 162 mg subcutaneous injection once a week - ESR, ERYTHROCYTE SEDIMENTATION RATE; Future - C REACTIVE PROTEIN, INFLAMMATORY; Future - ESR, ERYTHROCYTE SEDIMENTATION RATE - C REACTIVE PROTEIN, INFLAMMATORY - CBC WITH AUTOMATED DIFFERENTIAL; Future - AST, ASPARTATE AMINOTRANSFERASE; Future - ALT, ALANINE TRANSAMINASE; Future - CREATININE; Future - ESR, ERYTHROCYTE SEDIMENTATION RATE; Future - C REACTIVE PROTEIN, INFLAMMATORY; Future   4. Long term current use of systemic steroids Side effects including increased risk of infections, weight gain, cataracts, glaucoma, worsening hyperglycemia/diabetes, gastric ulcers, thinning of skin, bruising, osteoporosis,etc discussed with the patient. Patient advised to consider taking vitamin D3 supplementation over-the-counter   5. Encounter for long-term (current) use of high-risk medication Check blood counts, kidney and liver function tests periodically for drug toxicity monitoring for Actemra TB QuantiFERON negative       Return in about 1 month (around 7/14/2021).    Counseled Patient regarding medication(s) side effect(s), diagnostic results, impressions, prognosis, risks and benefits of treatment options    MD     ___________________________________________________________________   HPI-    Patient is a 62 year old female  and presents for chief complaint of follow-up visit for giant cell arteritis with extracranial involvement with pain in extremities especially right arm, arteritis/vasculitis on CT angio, elevated markers of inflammation diagnosed 05/2021, symptoms started 2 weeks after 2nd dose of COVID vaccination Raynaud's phenomena, weakly positive RNP antibody currently on prednisone 40 mg daily, Actemra 162 mg subcutaneous injection once a week   Interval Events- Patient states she is feeling much better as compared to before. She has noticed improvement in pain in her arms as well as blood pressure readings at home. She feels a little shaking in the morning on prednisone and has been doing somewhat better than before. She is feeling puffiness in her face. Brain fog present. She has been sleeping okay at night. Rest of her joints are feeling okay with no pain, no skin rashes. No fever/chills, night sweats. No significant headache, jaw pain.   Rheum ROS:  Constitutional: As stated in history of present illness     PHYSICAL EXAM: Physical Exam General Appearance: Alert, cooperative, no distress, appears stated age  Respiratory: In no apparent respiratory distress, no visibile retractions, no audible wheezes, speaks in full sentences Skin: visualized areas of normal color, without pallor or rubor Musculoskeletal: No swelling visible at MCPs, PIP, wrists, good fist making   LABS/IMAGING:  I reviewed the following test results with the patient. Lab Results Component Value Date   WBC 15.9 (H) 06/02/2021   RBC 4.25 06/02/2021   HGB 12.0 06/02/2021   HCT 36.7 06/02/2021   MCV 86.4 06/02/2021   MCH 28.2 06/02/2021   MCHC 32.7 06/02/2021   RDW 14.7 06/02/2021   PLT 431 (H) 06/02/2021   DIFFTYP Automated 09/19/2019   NEUTP 60.5 06/02/2021   LYMPHP 33.3 06/02/2021   MONOSP 5.6 06/02/2021   EOSP 0.4 06/02/2021   BASOP 0.2 06/02/2021   NEUTABS 4.4 09/19/2019   LYMPHABS 2.2 09/19/2019   MONOSABS 0.5 09/19/2019   EOSABS 0.2 09/19/2019   BASOABS 0.0 09/19/2019   Lab Results