Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Rheumatology
Sample Name: Rheumatoid Arthritis

Description: A sample note on Rheumatoid Arthritis
(Medical Transcription Sample Report)

RHEUMATOID ARTHRITIS (or RA) is a chronic, systemic condition with primary involvement of the joints. Joint inflammation is present due to an abnormal immune response in which the body attacks its own tissue. Specifically, the tissues lining the joint are involved as well as cartilage and muscle and sometimes the eyes and blood vessels. The cause of rheumatoid arthritis is obscure but it is associated with a family history, genetic and autoimmune problems, people ages 20-60, female gender 3:1 or a Native American background.

SIGNS AND SYMPTOMS:
* Joint pain, swelling, redness, warmth. Commonly involved joints are the small joints of the hands and feet and the ankles, wrists, knees, shoulders and elbows.
* Multiple swollen joints (more than 3) with simultaneous involvement of same joints on opposite side of the body.
* Morning stiffness that lasts longer than 30 minutes.
* Difficulty making a fist; poor grip strength.
* Night pain.
* Feeling "sick" - low fever, loss of appetite, tiredness, generalized aching and stiffness, weakness.
* Rheumatoid nodules under the skin, usually along the surface of tendons or over bony prominences.
* Disease may lead to deformed joints, decreased vision, anemia, muscle weakness, peripheral nerve problems, pericarditis, enlarged spleen, increased frequency of infections.
* Blood tests will reveal a positive rheumatoid factor (RF) to be present the majority of the time.

TREATMENT:
* To diagnose RA, blood studies are done to detect a substance known as rheumatoid factor and x-rays may show typical findings.
* Night splints for involved joints. Avoid putting a pillow under the knees as this will contribute to joint contracture.
* Heat helps relieve the pain; hot water soaks, whirlpool baths, heat lamps, heating pads, etc. applied to affected joints 15-20 minutes 3 times per day is helpful.
* Sleep on a firm mattress and sleep at least 10-12 hours per night. Get rest during the day; take naps.
* Get bed rest during an active flare-up until symptoms subside.
* Avoid humid weather if possible.
* NSAIDs (non-steroidal anti-inflammatory drugs).
* DMARDs (disease-modifying anti-rheumatic drugs) - gold compounds, D-penicillamine, sulfasalazine, methotrexate, antimalarials.
* Immunosuppressive drugs.
* Acetaminophen (Tylenol) for pain relief only when necessary.
* Oral corticosteroids short term; corticosteroid injection into joint can temporarily relieve pain and inflammation.
* Exercise as recommended by your physician. Exercise helps keep the joints limber and increases strength. Swimming and water activities are a good way to workout. Put all your joints through their full ranges of motion every day to prevent contractures. * Physical therapy may be recommended.
* Surgical intervention.
* Lose excess weight as being overweight will only stress the joints further.
* Eat a normal, well-balanced diet.

Keywords: rheumatology, ra, rheumatoid arthritis, joint inflammation, swollen joints, arthritis, joints, inflammation, corticosteroids, rheumatoid,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples